Employment Application

PERSONAL INFORMATION

Name (Last, First, Middle Initial)

Street Address

City, State, Zip Code

Phone Number	Email Address

Position Desired	When are you available to work?
	Days Nights Weekends Full-time Part-time

Please specify days and hours desired	Are you currently enrolled in school?

Please rate your computer & internet skills | 1= Not Very Efficient - 5=Very Efficient

Have you ever worked for Horizons Unlimited?	Are you related to any of our employees?	Are you related to anyone to whom we provide services?

On what date would you be available for work?	Are you eligible to work in the United States?
	(If offered employment, you will be required to provide documentation to verify eligibility.)

BACKGROUND INFORMATION

Do you have a record of founded child or dependent adult abuse?
If you have, please give details?

Have you ever been convicted of a crime, in this or any other state? (Conviction does not constitute an automatic bar to employment)
If the conviction or record is from a state other than Iowa, please list

Do you have or are you eligible to obtain a valid Driver's License?	If required, would you be willing to obtain a Chauffeurs License?

Whate state?

Do you have any violations in the past 7 years on your motor vehicle record?	Do you have high risk insurance?

Are you currently employed?

EDUCATION/SKILLS: Please list all education beginning with most recent.

	Name & Location of School	# of yrs. Complete	Graduated	Degree &/or Major
High School/GED
College
Graduate School
Trade School/Other

REFERENCES: Please list three professional references. By listings these references, CCSI assumes we may contact these people. Do not list relatives.

Name	Address	Business	Phone

EMPLOYMENT HISTORY: List your four most recent positions relevant to the position you are applying for.

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.				Position Title
From:		To:

Salary		Organization Name/Address
Start:	Final:
I was paid:
Employment Type:
Hours worked per week:

May we contact your references?	Supervisor's Name/Title/Phone

Reason for leaving:
Please explain your reason for leaving

Duties:

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.				Position Title
From:		To:

Salary		Organization Name/Address
Start:	Final:
I was paid:
Employment Type:
Hours worked per week:

May we contact your references?	Supervisor's Name/Title/Phone

Reason for leaving:
Please explain your reason for leaving

Duties:

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.				Position Title
From:		To:

Salary		Organization Name/Address
Start:	Final:
I was paid:
Employment Type:
Hours worked per week:

May we contact your references?	Supervisor's Name/Title/Phone

Reason for leaving:
Please explain your reason for leaving

Duties:

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.				Position Title
From:		To:

Salary		Organization Name/Address
Start:	Final:
I was paid:
Employment Type:
Hours worked per week:

May we contact your references?	Supervisor's Name/Title/Phone

Reason for leaving:
Please explain your reason for leaving

Duties:

How did you find out about this job opportunity?

Please state any additional information you feel may be helpful to us in considering your application, i.e., volunteer experience, previous training not listed elsewhere, etc.

Disclaimer & Signature – I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Digital Signature:	Spam Check:	What does 1+3=

2107 Main Street
P.O. Box 567
Emmetsburg, IA 50536
Call: 712-852-2211
Email Us