Application For Employment

Please print; use additional sheets if necessary. Conditions of employment are stated at the end of this form. Please read carefully before you sign and submit this application.
Date of application:(*)

Position(s) applied for:(*)
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PERSONAL INFORMATION
First Name(*)
Please type your first name.

Last Name(*)
Please type your last name.

Middle Name
Please type your last name.

Street Address:(*)
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City:(*)
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State:(*)
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Zip:(*)
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Phone:(*)
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E-mail(*)
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Are any of your relatives presently employees, board members, or service recipients with our agency?(*)
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If yes, name of relative:
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Have you ever worked for our agency before?(*)
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If yes, position title and dates of employment:
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Have you ever applied for employment with our agency before?(*)
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If yes, when:
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Referral Source
(if referred by a current employee list their name):
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GENERAL INFORMATION
Are you at least 18 years of age?(*)
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Are you legally eligible for employment in the United States?(*)
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(Note: Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment with our agency. Employment is subject to verification of U.S. citizenship or authorized alien status in accordance with the Immigration Reform and Control Act of 1986.)

Backround Check
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Search, Inc. is required by the Illinois Department of Public Health (IDPH) to ensure that all employees meet qualifications as found in the Health Care Worker Background Check Act (225 ILCS46). Completion of fingerprinting and a criminal background check upon hire are mandatory for employment with Search, Inc. IDPH considers certain convictions to be “disqualifying” and individuals with disqualifying convictions are prohibited from working for Search, Inc. A list of disqualifying convictions can be found at http://www.idph.state.il.us/nar/disconvictions.htm Additionally, Search, Inc. is required by the Illinois Department of Human Services (DHS) to submit a Child Abuse and Neglect Tracking System (CANTS) check for all new hires. A finding of abuse or neglect will prevent one from starting or continuing employment with Search, Inc.

(*)
You must select that you understand the background check statement

Have you ever been discharged from any employment or asked to resign?(*)
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If yes, please explain:
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Do you have a valid state driver’s license?(*)
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Have you been convicted of more than three traffic violations in the past year?(*)
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List all traffic violations in the past five years which resulted in a conviction, or a guilty plea:
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POSITION SPECIFICATIONS
Full Time
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Part Time
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Seasonal
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What days and hours are you available for work?(*)
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(Note: Work schedules are based upon the needs of the business and may be subject to change.)

Date available for work?(*)
Please select a date when we should contact you.

POSITION CRITERIA
Are you willing to provide care to individuals, such as:
Helping individuals who are unable to toilet themselves.(*)
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Helping individuals who are unable to feed themselves.(*)
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Are you willing to assist individuals that have behavioral challenges if:
There is a possibility that an individual may hit, kick, or bite you.(*)
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If someone exhibits inappropriate sexual behavior or uses profanity.(*)
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Are you willing to assist individuals that have physical challenges by:
Lifting and/or assisting individuals that are non ambulatory.(*)
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Learning to use mechanical devices to assist individuals.(*)
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ATTENDANCE AND PUNCTUALITY INFORMATION
Consistent attendance and punctuality are essential requirements of every job with this agency.
Is there anything which would interfere with your regular attendance and punctuality if you were offered a job with the agency?(*)
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If yes, please explain:
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EDUCATION
Grammar School
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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High School
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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College/ University
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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Vocational/ Business
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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Other School
Name & Address
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Number of Years Completed
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Did You Graduate?
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Degree or Diploma
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ADDITIONAL EXPERIENCE OR QUALIFICATIONS
List any other experience, skills or other qualifications, which you believe should be considered in evaluating your qualifications for employment:
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Please write a brief statement (3 or 4 sentences) explaining why you want to work for Search Inc. (Please pay attention to spelling and punctuation):
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EMPLOYMENT HISTORY
(Starting with Most Recent)
Name of Employer:
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Address:
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City:
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State:
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Zip:
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Type of Business:
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Telephone Number.:
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Your Supervisor’s Name:
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Your Position Duties:
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Date of Employment:
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Date of Employment:
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Pay Rate Starting
(state hourly or salary):
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Pay Rate Ending
(state hourly or salary):
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Reason for Leaving:
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Name of Employer:
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Address:
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City:
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State:
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Zip:
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Type of Business:
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Telephone Number.:
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Your Supervisor’s Name:
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Your Position Duties:
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Date of Employment:
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Date of Employment:
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Pay Rate Starting
(state hourly or salary):
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Pay Rate Ending
(state hourly or salary):
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Reason for Leaving:
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Name of Employer:
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Address:
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City:
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State:
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Zip:
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Type of Business:
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Telephone Number.:
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Your Supervisor’s Name:
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Your Position Duties:
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Date of Employment:
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Date of Employment:
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Pay Rate Starting
(state hourly or salary):
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Pay Rate Ending
(state hourly or salary):
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Reason for Leaving:
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REFERENCES
(Do Not List Relatives)
Reference 1
Name:
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Address:
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City:
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State:
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Zip:
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Occupational Title/Relationship:
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Telephone Number.:
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Length of Relationship:
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Reference 2
Name:
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Address:
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City:
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State:
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Zip:
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Occupational Title/Relationship:
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Telephone Number.:
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Length of Relationship:
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PLEASE READ AND SIGN BELOW
In consideration of the acceptance and processing of my application for employment, and of my employment with Search Inc. (Search), if I am employed, I hereby warrant and represent as follows:

1. Certification. I certify that I have not knowingly withheld any information that might adversely affect my chances for employment with Search and that the information given by me is true and correct without any mental reservation whatsoever. I understand that any omission or misstatement of material fact on my employment application, resume, or any other document used to secure employment with Search, Inc., or during any pre-employment interview, shall be grounds for rejection of my application or for immediate discharge if I am hired, regardless of the time elapsed before discovery.
I understand that if I am hired; my employment with Search requires submission to fingerprinting and a criminal background check per Search’s license through the Illinois Department of Public Health (IDPH) and should any “disqualifying conviction(s) ” as defined by the IDPH be in evidence on my record it will prevent me from starting or continuing employment with Search. I also understand that if I am hired; my employment with Search requires submission of a Child Abuse and Neglect Tracking System (CANTS) check and I will be unable to start or continue employment with Search, Inc. should a finding/indication/hit of abuse or neglect be returned.

2. Reference and Background Check. I authorize Search to thoroughly investigate my references, work record, education, and any other matters related to my suitability for employment. I also authorize my former employers to disclose to Search any and all of my employment records, including disciplinary reports and letters of reprimand, without giving me notice of such disclosure. I hereby fully release and discharge Search, my former employers, their respective officers, employees and agents, and all other persons and entities, from any and all claims, demands, and liabilities arising out of or in any way related to such investigation or disclosure. I understand that if I am hired; my employment with Search requires submission to fingerprinting and a criminal background check per Search’s license through the Illinois Department of Public Health (IDPH) and should any “disqualifying conviction(s)” as defined by the IDPH be in evidence on my record it will prevent me from starting or continuing employment with Search. I also understand that if I am hired; my employment with Search requires submission of a Child Abuse and Neglect Tracking System (CANTS) check and I will be unable to start or continue employment with Search, Inc. should a finding/indication/hit of abuse or neglect be returned.

3. At-Will Employment. I understand and agree that if I am hired, my employment and compensation are for no definite or determinable period and may be terminated at any time, with or without cause, warning or notice, at the option of either myself or Search. I further understand and agree that no representative of Search is authorized to make any binding representations or agreements, whether oral or written, contrary to the foregoing or purported to guarantee any particular benefits, terms, or conditions of employment.

4. Re-Application Policy. I understand that under Search's policy, this application will remain active for only sixty (60) days. Therefore, if I have not been hired within sixty (60) days of the date of this application and I still wish to be considered for employment with Search, I understand that I will need to complete and submit a new employment application.
Applicant Signature(*)
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Date:(*)
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Please enter the following text(*)
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