EMPLOYMENT APPLICATION
Christian Home AssociationChildren’s Square U.S.A.
Council Bluffs, Iowa 51502-3008
(712) 322-3700
Dear Applicant:
Thank you for your interest in employment at Christian Home Association-Children’s Square U.S.A.. The
agency was founded in 1882 (incorporated 1883) and has a rich history. A wide variety of services are provided
to foster the social, emotional, cognitive and educational development of children and families. Employees are
key to the delivery of the mission, which is:
To teach each child, every day, the values and life skills essential to a successful
life - one full of caring, contribution and commitment –
It is our belief that children are this nation’s most valuable resource and their families are the most
important factor in their development. We recognize the unique importance of each child and our
philosophy and programs develop individual abilities and talents, building in each:
The Vision To See...
And the value of setting an ideal for which to reach;
The Courage To Try...
And the value of accepting each obstacle as a challenge to meet; and
The Will To Succeed...
And the value of making the commitment to persevere.
APPLICANT INSTRUCTIONS
1. Please complete the application in neat, legible handwriting using blue or black ink. Your application must
be completed, front and back, providing all information required to evaluate your job application. The
application must be complete with date(s) of employment, job titles, reasons for leaving, schools you
attended, current mailing address, telephone number(s) and social security number. Complete address must
be provided for schools and previous employers, including street number, street, city, state and zip code.
2. If you need help to fill out this application form or help at any phase of the employment process, please
notify the person that gave you this form.
THIS ORGANIZATION IS AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER.
Applicants are considered for employment without regard to race, color, national origin, ethnicity, sex,
religion, creed, political affiliation, age, marital status or disability unrelated to job performance or
veteran status.
CHRISTIAN HOME ASSOCIATION
CHILDREN’S SQUARE U.S.A.
Date________________________________________
Name
(Last)
(First)
(Middle)
Address___________________________________________________________________________________
(Street)
(City)
_____________________________________
Area Code/Telephone Number
(State)
(Zip Code)
________________________________________________
Social Security Number
Position(s) applied for: ______________________________________________________________________
Have you ever been known by any other name? ___________________________________________________
Are you legally eligible for employment in the U.S.A.? Yes ____No ____ (If yes, verification will be required).
Have you ever applied for a position here before? Yes____ No____ If so, please give the date______________
Do you have a valid drivers license? Yes_____ No _____ (Required for some positions.)
Has your driver’s license been suspended or revoked in the last two years? Yes _____ No _____
If yes, explain fully._________________________________________________________________________
__________________________________________________________________________________________
Do you have a record of founded child or dependent adult abuse or are you currently under investigation for
this? Yes_____ No _____ If yes, explain fully.
__________________________________________________________________________________________
__________________________________________________________________________________________
Are there any charges of a crime pending or have you ever been convicted of a crime in this state or any other
state? Yes _____ No _____ If yes, explain fully.
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you related to an employee of this agency, member of the Board of Directors, or is any member of your
household employed by the agency? Yes _____ No _____ If yes, please give the:
Name__________________________________ Relationship to you __________________________________
NAME AND ADDRESS OF SCHOOLS ATTENDED (starting with high school)
Name and Address
Course
of Study
Number of
Years
Completed
Did You
Graduate
Degree or Diploma
ADDITIONAL TRAINING/LICENSES/CERTIFICATIONS: (List licenses, certifications or trainings you
have obtained related to the Human Services field.)
__________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
*****
LIST MEMBERSHIP(S) IN JOB RELATED, PROFESSIONAL ORGANIZATIONS (You may exclude
any information that would disclose race, age, ethnic origins or religious or political persuasion or
affiliation).
__________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please print and list every position that you have held for the past ten years or last five employers, starting with
your most recent position first and noting any periods in which you were not employed in the section marked
“Additional Information.” Please include military service.
EMPLOYMENT BACKGROUND: Present or most recent position.
May we contact your present
employer for a reference?
Yes ______ No ______
Employer ________________________________________________
Phone________________________
Address _________________________________________________
Employed From (Mo./Yr.) _______
__________________________________________________________________________
Employed To (Mo./Yr.) _________
Name and Title of Supervisor ________________________________
Length of Employment _________
Position(s) held ___________________________________________
Starting Base Pay ______________
Duties ___________________________________________________
Ending Base Pay ______________
_________________________________________________________
Full-time ______ Part-time ______
_________________________________________________________
On-call ______
Reason for Leaving _________________________________________________________________________
_________________________________________________________________________________________
EMPLOYMENT BACKGROUND: Previous Position.
Employer ________________________________________________
Phone________________________
Address _________________________________________________
Employed From (Mo./Yr.) _______
__________________________________________________________________________
Employed To (Mo./Yr.) _________
Name and Title of Supervisor ________________________________
Length of Employment _________
Position(s) held ___________________________________________
Starting Base Pay ______________
Duties ___________________________________________________
Ending Base Pay ______________
_________________________________________________________
Full-time ______ Part-time ______
_________________________________________________________
On-call ______
Reason for Leaving _________________________________________________________________________
_________________________________________________________________________________________
EMPLOYMENT BACKGROUND: Previous Position.
Employer ________________________________________________
Phone________________________
Address _________________________________________________
Employed From (Mo./Yr.) _______
__________________________________________________________________________
Employed To (Mo./Yr.) _________
Name and Title of Supervisor ________________________________
Length of Employment _________
Position(s) held ___________________________________________
Starting Base Pay ______________
Duties ___________________________________________________
Ending Base Pay ______________
_________________________________________________________
Full-time ______ Part-time ______
_________________________________________________________
On-call ______
Reason for Leaving ________________________________________________________________________
_________________________________________________________________________________________
EMPLOYMENT BACKGROUND: Previous Position.
Employer ________________________________________________
Phone________________________
Address _________________________________________________
Employed From (Mo./Yr.) _______
__________________________________________________________________________
Employed To (Mo./Yr.) _________
Name and Title of Supervisor ________________________________
Length of Employment _________
Position(s) held ___________________________________________
Starting Base Pay ______________
Duties ___________________________________________________
Ending Base Pay ______________
_________________________________________________________
Full-time ______ Part-time ______
_________________________________________________________
On-call ______
Reason for Leaving ________________________________________________________________________
_________________________________________________________________________________________
EMPLOYMENT BACKGROUND: Previous Position.
Employer ________________________________________________
Phone________________________
Address _________________________________________________
Employed From (Mo./Yr.) _______
__________________________________________________________________________
Employed To (Mo./Yr.) _________
Name and Title of Supervisor ________________________________
Length of Employment _________
Position(s) held ___________________________________________
Starting Base Pay ______________
Duties ___________________________________________________
Ending Base Pay _______________
_________________________________________________________
Full-time ______ Part-time ______
_________________________________________________________
On-call ______
Reason for Leaving _________________________________________________________________________
_________________________________________________________________________________________
ADDITIONAL INFORMATION: List any relevant volunteer work and all periods of unemployment
during the past 10 years.
FROM
MO./YR.
TO
MO./YR.
DESCRIPTION OF ACTIVITIES OR VOLUNTEER WORK
CHRISTIAN HOME ASSOCIATION-CHILDREN’S SQUARE U.S.A.
AUTHORIZATION FOR JOB REFERENCE CHECK
Please provide four references of which two must be persons who directly supervise you.
_____________________________________________
Name of Reference
__________________________________________
Title
_____________________________________________
Company Name
__________________________________________
Street Address
_________________________________________________________________________________________
City
State
Zip Code
____________________________________________
Work Phone
_________________________________________
Home Phone
I hereby authorize the above named reference to answer any job related questions posed by Christian Home
Association-Children’s Square U.S.A. in order to further my application process.
_____________________________________________
Signature of Applicant
_________________________________________
Date
_________________________________________ __________________________________________
Name of Reference
Title
_____________________________________________
Company Name
__________________________________________
Street Address
_________________________________________________________________________________________
City
State
Zip Code
____________________________________________
Work Phone
_________________________________________
Home Phone
I hereby authorize the above named reference to answer any job related questions posed by Christian Home
Association-Children’s Square U.S.A. in order to further my application process.
_____________________________________________
Signature of Applicant
_________________________________________
Date
CHRISTIAN HOME ASSOCIATION-CHILDREN’S SQUARE U.S.A.
AUTHORIZATION FOR JOB REFERENCE CHECK
Please provide four references of which two must be persons who directly supervise you.
_____________________________________________
Name of Reference
__________________________________________
Title
_____________________________________________
Company Name
__________________________________________
Street Address
_________________________________________________________________________________________
City
State
Zip Code
____________________________________________
Work Phone
_________________________________________
Home Phone
I hereby authorize the above named reference to answer any job related questions posed by Christian Home
Association-Children’s Square U.S.A in order to further my application process.
_____________________________________________
Signature of Applicant
_________________________________________
Date
_____________________________________________
Name of Reference
__________________________________________
Title
_____________________________________________
Company Name
__________________________________________
Street Address
_________________________________________________________________________________________
City
State
Zip Code
____________________________________________
Work Phone
_________________________________________
Home Phone
I hereby authorize the above named reference to answer any job related questions posed by Christian Home
Association-Children’s Square U.S.A. in order to further my application process.
_____________________________________________
Signature of Applicant
_________________________________________
Date
PLEASE READ CAREFULLY BEFORE SIGNING

I have read and understand this application and certify that the information contained in this application is
true and correct and I understand that any falsification, misrepresentation or omission on this application is
grounds for refusal to hire or, if hired, for subsequent discipline up to and including dismissal from
employment.

I authorize all persons, schools, current or former employers, law enforcement authorities, whether listed or
not listed on this application, to release any information concerning my background and work experience
and hereby release and hold harmless, Christian Home Association-Children’s Square U.S.A., its divisions
or related businesses and entities, their employees, officers, directors, or agents, as well as, any said persons,
schools, companies and law enforcement authorities from any liability for any damage whatsoever for
providing or issuing this information.

I understand that Christian Home Association-Children’s Square U.S.A. maintains a drug free and tobaccofree workplace and that maintenance of same is essential to the safety of the workplace and employees.

Initial and continued employment at Christian Home Association-Children’s Square U.S.A. is contingent
upon successful completion of a criminal records check, child abuse checks, reference checks, motor
vehicle driving records, successful completion of a physical examination at any time requested and the
ability to perform the essential duties of the job.

I understand that, if hired, my employment is considered to be at will and can be terminated by either party
at any time with or without cause. Christian Home Association-Children’s Square U.S.A. reserves the right
to terminate without any notice. I understand that this application and any other handbook or documents
which I may receive are not contracts of employment. I acknowledge that my offer of employment is
conditional and may be withdrawn at any time.
______________________________________________________________
__________________________________________
Signature of Applicant
Date
Revised 8/92; 8/93; 4/97;1/08
Forms/application
REPLY TO
ATTN OF:
U.S.A.
CHILDREN'S SQUARE
DATE
SUBJECT: REQUEST FOR CRIMINAL HISTORY INFORMATION
TO: NEBRASKA STATE PATROL
CRIMINAL IDENTIFICATION DIVISION
3800 NW 12TH SUITE A
LINCOLN, NE 68521
CRIMINAL HISTORY REQUESTED
NAME (PRINT LAST/FIRST/M.I.):
D.O.B.:
DATE:
LAST KNOWN ADDRESS:
CITY:
STATE:
S.S.#:
MAIDEN NAME/ALIAS:
ZIP CODE:
I HEREBY AUTHORIZE THE RELEASE OF ANY AND ALL CRIMINAL
HISTORY INFORMATION MAINTAINED ON ME TO:
NAME (PRINT LAST/FIRST/M.I.)
SIGNATURE
SIGNATURE OF REQUESTER
Phone: (800) 691-0919 Fax: (402) 691-9496
RELEASE AUTHORIZATION
APPLICANT: This release must be filled out completely for your application to be considered.
Name:
Last
First
Middle
Ver. 12/12
**APPLICANT COMPLETE THIS
SECTION**
* List Each City & State of Residence or
Employment For the Most Recent 7 Years *
Maiden / Previous Name (s)
Home Address
___________________________________ _______
City
State
___________________________________ _______
Zip
___________________________________ _______
SSN - Social Security Number
DOB - Date Of Birth
MVR - Issuing State
Driver’s License Number
___________________________________ _______
___________________________________ _______
In connection with my application for employment, volunteer, or contractor status, I authorize any, employer, educational institution, law
enforcement organization, state and federal government agency, information bureau, and other persons contacted to release information regarding my
character, performance, qualifications, background and reasons for termination of past employment to company or its agent and release all parties involved
in providing said information from any responsibility or liability.
I also authorize the release of my driving history, criminal records, employment confirmation and other consumer investigative report information
for current retrieval as an applicant, volunteer or contractor or future retrieval as an employee, if hired. I understand a Consumer Reporting Agency (CRA)
such as Protec Systems, may obtain a Consumer Investigative Report (CIR) on me and that the CIR may contain information about my background, mode of
living, character, and personal reputation. I acknowledge that a telephone facsimile, photographic or electronic signature shall be as valid as an original
signature. I understand that the decision to hire is solely that of the employer, and although said decision may be based upon information gathered by
PROTEC Systems, I release PROTEC Systems from any and all liability surrounding or related to the employer’s decision.
□ New York / Maine applicants-employees only: You have the right to inspect and receive a copy of your Consumer Investigative Report by
contacting Protec Systems, LLC identified above directly.
□ Minnesota / Oklahoma applicants-employees only: Please check this box if you would like to receive a copy of your consumer report if one is
obtained by the Company.
□ Oregon applicants-employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft
protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained
secured records is available to you upon request.
□ Washington applicants-employees only: You also have the right to request from the consumer reporting agency a written summary of your
rights and remedies under the Washington Fair Credit Reporting Act.
__________________________________________________________________________________________________________________________
Applicant’s Signature
Date
Employer - Complete This Section
* If Service(s) Ordered Online – Check Here ______*
HE22278
Client Access Number
____Rachel Radel_________________________________
Contact Name
Childrens Square, USA
Company Name
(402) 322-3700
Phone Number
_____________________________________________
(712) 323-6968
Fax Number
Employer - Check Each Service Requested
□Address Location & SSN Search (ALS)
□Social Security Number Verification (SSN) - See Above
□*Motor Vehicle Record (MVR) – See Above-fax release form
□Academic Verification (AEV) - See Above
□Professional License Verification (PLV) - See Above
□Personal Re
- Fax Names & Ph. #
- Fax Work History
□Sexual Offender Search (SOS) State (s)______________
□Civil Record Search (CRS)
□Criminal History Check (CHC)
Search: City or County - past 7 years
State
____________________________________________ ________
____________________________________________ ________
Department of Health & Human Services
N
E
B
R
A
S
K
A
Division of Children and Family Services
Agency Request for Information from the Nebraska
Adult and Child Abuse and Neglect Register/Registry
I hereby request information from the Nebraska Adult and Child Abuse and Neglect Registry. I agree to use the requested
information to determine whether to hire or retain the individual to provide care, custody, treatment, transportation or
supervision of children or vulnerable adults.
Agency Name
Fax Number
Children's Square USA
712-323-6968
Address
Phone Number
PO Box 8C Council Bluffs IA 51502
712-322-3700
I hereby authorize the Division of Children and Family Services to disclose whether I have an Adult and/or Child Abuse and
Neglect Register/Registry record to the above-named agency.
Full Legal Name (applicant)
Address
City/State
Date of Birth
Social Security Number
Zip
Other names previously used such as former married names, maiden name and nick names.
Names and birth dates of your children and children who have lived with you.
Any Address at which you have resided during the past 20 years.
Signatures and Dates
Print full legal name
Signature Date
CSE-72 Rev. 4/12 (05015)
Use previous version 11/11 first
CHRISTIAN HOME ASSOCIATION-CHILDREN’S SQUARE U.S.A.
I.
NOTIFICATION OF PROCUREMENT OF CRIMINAL HISTORY RECORDS CHECKS, CHILD
ABUSE INFORMATION REPORTS, DEPENDENT ADULT ABUSE INFORMATION REPORTS, SEX
OFFENDER REGISTRY, MOTOR VEHICLE RECORD CHECK, AND CONSUMER REPORT
Christian Home Association-Children’s Square Association-Children’s Square U.S.A. strives to provide quality services
through quality employees. As one of our steps to ensure this, we conduct pre-employment Criminal History Record
Checks, Child Abuse Information Reports, Dependent Adult Abuse Information Reports, Sex Offender Registry Checks,
and a post employment Motor Vehicle Record Check.
Christian Home Association-Children’s Square U.S.A. and any of its authorized officers, employees, or agents may procure
a consumer report concerning an employee or applicant for employment purposes. The consumer report may include, but is
not limited to, a written, oral or other communication bearing on the employee’s or applicant’s credit, character, general
reputation, personal characteristics, or mode of living. The consumer report will include information bearing on the
criminal history and/or credit history of the employee or applicant. Such information may be used to evaluate whether the
employee or applicant is an appropriate candidate for employment, promotion, reassignment, or retention and this
determination could be adverse to the employee or applicant.
To assist us in having information available on a timely basis, to fulfill state requirements, we request that applicants
complete the attached forms when they are interviewed. If it is decided to proceed further in the hiring process, these may
be submitted to the appropriate government bodies for processing.
We appreciate your assistance in this matter and ask that you complete this form and attached documentation.
II.
BACKGROUND CHECK AUTHORIZATION
Name (Print First/Middle/Last)
Address ______________________________________________________________________________________
City, State, Zip ________________________________________________________________________________
Date of Birth __________________________________________________________________________________
Social Security # _______________________________________________________________________________
County _______________________________________________________________________________________
Driver’s License Number
State of issue __________________________________________________________________________________
I authorize Christian Home Association-Children’s Square U.S.A. and any of its authorized officers, employees and agents
to conduct an investigation into my background and to obtain a consumer report concerning my criminal or credit history. I
also authorize Christian Home Association-Children’s Square U.S.A. to use any lawful means it deems appropriate to
conduct the investigation, including personal interviews of people who have knowledge of me or my criminal or credit
history. I further authorize any reporting agency, individual, or branch of state, local or federal government, or others with
any information concerning my background, to compile and furnish such information in any form to Christian Home
Association-Children’s Square U.S.A and any of its authorized officers, employees or agents.
I agree to cooperate in this investigation, and I release from all claims and liabilities any person who complies, provides,
receives or acts upon information or documents pursuant to this authorization. I acknowledge that such information may be
used to evaluate whether I am an appropriate candidate for employment, and that this determination could be adverse to me.
This authorization shall remain effective indefinitely and may only be revoked by actual notice delivered by me to the Chief
Financial Officer.
Signed:
08/02 06/04 DW/dd MW/dd 1/08
Date: _____________________________