Employment Application - Alcohol and Drug Dependency Services of Southeast Iowa

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Cell Phone

Email*

Positions(s) for which you are applying*

Available for (check all that apply)*

Full Time
Part Time
On-Call
Temporary / Seasonal

How did you hear about us?*

Newspaper Ad
Employment agency
Current Employee

On what date would you be available to begin work?*

Salary or rate of pay desired if employed?*

Are you legally able to work in the United States?*

Yes
No

(Proof of eligibility will be required opun offer of employment)

Are you 18 years of age or older?*

Yes
No

(If no, you may be required to provide authorization)

Have you ever applied to ADDS before?*

Yes
No

Date of previous application to ADDS*

Have you ever worked for ADDS before?*

Yes
No

Dates of previous ADDS employment*

Have you ever been excluded or debarred from participating in Federal Health Care Programs?*

Yes
No

Please Explain*

Do you have a record of founded child or dependent adult abuse in this state or any other state?*

Yes
No

Please Explain*

Have you ever been convicted of a felony in this state or any other state or are there any criminal charges pending against you?*

Yes
No

"YES" does not automatically eliminate you from consideration

Please Explain*

Are you applying for a driving position?*

Yes
No

Do you have a valid Driver's license?*

Yes
No

Have you been convicted of any moving violations in the past five years?*

Yes
No

List license, registration, certifications currently held and/or skills relevant for this position

List U.S. Military or Naval Service (service dates and rank)

Education History

High School

School Location / Address

Subjects Studies or Major

Years Attended

Diploma or Degree Received

College 1

School Location / Address

Subjects Studies or Major

Years Attended

Diploma or Degree Received

College 2

School Location / Address

Subjects Studies or Major

Years Attended

Diploma or Degree Received

Employment History

Begin with current or most recent employer

May we check reference with your current employer?*

Yes
No

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position / Description of duties

Employment Dates

Name / Title of Supervisor

Supervisor phone / fax

Company Name 2

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position / Description of duties

Employment Dates

Name / Title of Supervisor

Supervisor phone / fax

Company Name 3

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position / Description of duties

Employment Dates

Name / Title of Supervisor

Supervisor phone / fax

References

List three persons not related to you or named above as a supervisor, who can attest to your work performance.

Name 1

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Business

Years Known

Name 2

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Business

Years Known

Name 3

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Business

Years Known

Applicant Acknowledgement and Authorization

Applicant Acknowledgement and Authorization*

I agree to the statement below

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I hereby authorize any and all employers, references, schools, and any others who have pertinent information about me to provide such information to ADDS and/or any of its representatives and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that if offered a position with ADDS, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment and that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I further understand that, should an offer of employment be extended, such employment is at-will and may be terminated by either ADDS or myself at any time, with or without cause or notice. BY SUBMITTING I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.