Opportunity Homes, Inc.

APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, martial or veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.

Applicants are required to have a high school diploma, GED, or equivalent, and a valid driver’s license.

PERSONAL INFORMATION

First Name

Last Name

Email

Provide email address or enter N/A

Address

City

State

Zip

Phone Number

Include area code

Best Time to Call

Referred By:

Walk-in

Ad

School

Iowa Workforce Development

Other

Employee

Date Available to Work:

Position Applying For:

Are you available to work: (check all that apply)

Full-time

Part-time

Temporary

Are you currently on lay-off status and subject to recall?

Yes No

Have you ever filed an application with us before?

Yes No

Are you prevented from lawfully becoming employed in this country because of visa or immigration status? (Proof of citizenship or immigration status will be required upon employment)

Yes No

Have you been convicted of a felony with the last 7 years?

Yes No (No applicant will be denied employment solely on the grounds of a conviction or pending criminal charge. The nature of the offense, the date, the surrounding circumstances, and relevance to the position applied for will be considered.)

Have you been convicted of Medicaid fraud?

Yes No

Do you have a record of founded child or dependent adult abuse or have you ever been convicted of crime in this state or any other state?

Yes No

EMPLOYMENT REFERENCES

NOTE Providing accurate fax numbers will expedite the reference check process.

EMPLOYER #1

Current/Most recent employer

From

Start Date - mm/dd/yyyy

To

End Date - mm/dd/yyyy

Supervisor's Name

First/Last name

May we contact?

Yes No

Employer's Address

Street/City/State/Zip

Employer's Phone #

Include area code

Employer's Fax #

Include area code; enter N/A if fax is unavailable

Position

Starting Wage

Final Wage

Reason for Leaving

Duties

EMPLOYER #2

Previous employer

From

Start Date - mm/dd/yyyy

To

End Date - mm/dd/yyyy

Supervisor's Name

First/Last name

May we contact?

Yes No

Employer's Address

Street/City/State/Zip

Employer's Phone #

Include area code

Employer's Fax #

Include area code; enter N/A if fax is unavailable

Position

Starting Wage

Final Wage

Reason for Leaving

Duties

EMPLOYER #3

Previous employer

From

Start Date - mm/dd/yyyy

To

End Date - mm/dd/yyyy

Supervisor's Name

First/Last name

May we contact?

Yes No

Employer's Address

Street/City/State/Zip

Employer's Phone #

Include area code

Employer's Fax #

Include area code; enter N/A if fax is unavailable

Position

Starting Wage

Final Wage

Reason for Leaving

Duties

PERSONAL REFERENCES

PERSONAL REFERENCE #1

First/Last name

Address

Street/City/State/Zip

Phone #

Include area code

Relationship

Years Known

PERSONAL REFERENCE #2

First/Last name

Address

Street/City/State/Zip

Phone #

Include area code

Relationship

Years Known

PERSONAL REFERENCE #3

First/Last name

Address

Street/City/State/Zip

Phone #

Include area code

Relationship

Years Known

EDUCATION

High School

Name of high school attended or enter GED

Location of High School

City/State

Course of Study

# of Years

Graduated?

Yes No

College

Name of college attended

Location of College

City/State

Course of Study

# of Years

Graduated?

Yes No

OTHER EXPERIENCE

Describe other life experiences which may pertain to the position for which you are applying (i.e. volunteer work, other training, special skills, etc.)

Provide any additional information you feel may be helpful to us in considering your application.

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this period should inquire as to whether or not applications are being accepted at that time.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

By checking this box, I certify that I agree with and understand the four statements listed above.

AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize Opportunity Homes, Inc. to contact my current and/or former employers, educational institutions I have attended, or other persons with whom I have acquaintance.

I am aware that Opportunity Homes, Inc. will conduct a records check for criminal & child and dependent adult abuse in this and other states.

By checking this box, I certify that I agree with and understand the two statements listed above.

REFERENCE REQUEST

Applicant's Name

To be completed by applicant

By checking this box, I (the applicant stated above), do hereby authorize the release of information obtained from current/previous employer(s) to Opportunity Homes, Inc. and relieve any individual and/or company completing a reference check of all legal responsibilities.