Apply Online Employment Application 1. Start 2. Background 3. Education / Training 4. Employment Experience 5. Other Applicant Information 6. References / Additional Info 7. Availability 8. Applicant's Statement Spam protection, skip this field Last name First name Middle Name (optional) Address Apt. # (optional) City State Zip Code Home Phone (optional) Cell Phone Email (optional) Are you 18 years of age or older? Yes No If hired, can you furnish proof you are eligible to work in the U.S? Yes No Have you ever applied at Reach for Your Potential before? Yes No When did you last apply? (optional) Month January February March April May June July August September October November December Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Have you ever worked for Reach for Your Potential? Yes No Please indicate when you last worked: (optional) Month January February March April May June July August September October November December Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Have you ever been convicted of or pleaded guilty to any law violation (except speeding or parking violations)? Yes No If yes, please give details of law violation(s) (optional) Are you now or do you expect to be engaged in any other employment? Yes No Please explain other employment: (optional) Do you have a valid driver’s license? Yes No *Many positions require the employee to provide transportation DL State (optional) DL Date Issued (optional) Have you had your driver’s license suspended or revoked in the last 3 years? (optional) Yes No If yes, provide suspension/revocation details: (optional) Name of High School Attended: H.S. Yrs. Attended H.S. Diploma/Degree/Cert. Earned: Please List Name of College Attended: (optional) College Yrs. Attended (optional) College Diploma/Degree/Cert. Earned: (optional) Please List College Subjects Studied/Majors (optional) Please List Name of Voc. or Tech School Attended: (optional) Voc/Tech Yrs. Attended (optional) Voc / Tech Diploma/Degree/Cert. Earned: (optional) Please List Voc/Tech Subjects Studied/Majors (optional) Please List What skills or additional training do you have that are related to the job for which you are applying? (optional) What machines or equipment can you operate that are related to the job for which you are applying? (optional) List professional, trade, business, or civic activities and offices held: (optional) Do not include labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, or other protected status. **Start with your present or most recent and list all prior employers. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. PLEASE GIVE MONTH AND YEAR. If you have no prior employment, enter "NA" into any required fields. Name of Employer (most recent or current) Job Title(s) Address (optional) City / State Dates of Employment Include month and year Employer Phone (important) (optional) Employer Fax Number (optional) Supervisor's Name May we contact for a reference check? Yes No Starting Pay Final Pay Reason for leaving Primary Job Duties Name of Employer 2 (optional) Job Title(s) (optional) Address (optional) City/State (optional) Dates of Employment (optional) Include month and year Employer Phone (optional) Employer Fax Number (optional) Supervisor's Name (optional) May we contact for a reference check? (optional) Yes No Starting Pay (optional) Final Pay (optional) Reason for leaving (optional) Primary job duties (optional) Name of Employer 3 (optional) Job Title(s) (optional) Address (optional) City/State (optional) Dates of Employment (optional) Include month and year Employer Phone (optional) Employer Fax Number (optional) Supervisor's Name (optional) May we contact for a reference check? (optional) Yes No Starting Pay (optional) Final Pay (optional) Reason for leaving (optional) Primary job duties (optional) Name of Employer 4 (optional) Job Title(s) (optional) Address (optional) City/State (optional) Dates of Employment (optional) Include month and year Employer Phone (optional) Employer Fax Number (optional) Supervisor's Name (optional) May we contact for a reference check? (optional) Yes No Reason for leaving (optional) Primary job duties (optional) Name of Employer 5 (optional) Job Title(s) (optional) Address (optional) City/State (optional) Dates of Employment (optional) Include month and year Employer Phone (optional) Employer Fax Number (optional) Supervisor's Name (optional) May we contact for a reference check? (optional) Yes No Reason for leaving (optional) Primary job duties (optional) Have you ever worked under any other name? Yes No If yes, please give name(s) (optional) Are you presently employed? Yes No May we contact your present employer? (optional) Yes No Have you ever been fired from a job or asked to resign? Yes No If yes, please explain: (optional) **Please give three personal references, not relatives for former employers. Reference 1 Name How do you know this person? Address (optional) City/State Phone Reference 2 Name How do you know this person? Address (optional) City/State Phone Reference 3 Name How do you know this person? Address (optional) City/State Phone State any additional information you feel may be helpful to us in considering your application: (optional) Please check all shifts that you are able to work. Only Residential Facilitators have set schedules; Direct Care staff do not have set schedules. If you want 40 or more hours you need to provide 80 or more hours of availability. (You should be available for twice as many shifts as you want.) Shifts (optional) Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9a-3p Monday Tuesday Wednesday Thursday Friday Saturday Sunday 3p-10p Monday Tuesday Wednesday Thursday Friday Saturday Sunday 10p-9a Monday Tuesday Wednesday Thursday Friday Saturday Sunday What is the ideal number of hours you would like to work in a week? What is the first day you are available to work? Are you able to work at a location that requires lifting/transferring of members? Yes No Are you comfortable working with members of the opposite sex? Yes No I agree to the above availability. I understand that any changes made to my availability before my potential date of hire need to be approved by the Human Resources Coordinator What is the best way to contact you? Cell Phone Home Phone Email What is the best time to call? (optional) Attachments (optional) Add file or drop file here. Hold tight! It's uploading... A cover letter and/or resume can be attached here. File type not allowed. File exceeds maximum size allowed. File already uploaded. Invalid file. Bad request. Delete Delete 2 of 2 file limit remaining BE SURE TO READ EACH STATEMENT CAREFULLY I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications. I understand that any investigation conducted may include a request for employment and educational history, credit reports, consumer reports, investigative consumer reports, driving record, and criminal history. I understand I may be required to successfully pass a drug-screening examination. I hereby consent to a pre-and/or post-employment drug screen as a condition of being hired or of my continued employment, if required. I acknowledge that I have been informed of prohibitions of the Iowa Smokefree Air Act. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I have read, understand, and consent to these statements. Type your name for signature Signature date Save draft