Independent Living Services, Inc. & Creative Living, Inc.
Application for Employment
Thank you for applying for employment. ILS is a private non‐profit agency whose mission is to help people with disabilities live as independently as possible in the community. ILS and Creative Living are Equal Opportunity Employers. We consider prospective employees without regard to race, color, creed, sex, religion, age, ethnic or national origin, disability, veteran or military status or any other classification protected by applicable law. Only job related matters are considered in making personnel decisions. ILS will make every effort to provide applicants with disabilities and any employees with reasonable accommodations necessary for completion of the application process or for the performance of their essential job duties if selected for employment.
Please fully complete this application. Your application will be kept on file for 90 days.
Please Print Clearly and in Ink
Name: ____________________________________
Daytime Phone: _______________________________
Street Address: _____________________________
E‐Mail or Alternative phone: _____________________
City/State/Zip: _____________________________
_____________________________________________
Position Applied For: ________________________
CIRCLE One: I prefer FULL / PART TIME / EITHER
Please indicate what Days & Hours you are Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
How did you hear about ILS:
Are you legally eligible for employment in the United States?
(Proof is required upon offer of employment)
Are you of legal age to work in the United States?
Under penalty of U.S. law you must be able to provide proof of employment eligibility.
Do you have the legal right to live and reside in the United States? Yes No If you are not a U.S. Citizen, please state visa type and # and/or your work permit # and explain:
Are you able to present the proper documentation of employment eligibility upon your date of hire?
Have you ever been employed here before? Yes No If yes, give dates:
Have you ever been involuntarily terminated from any employer other than job elimination or layoff?
Yes No
Yes No
If yes, please explain:
Are you related to any ILS or Creative Living employee?
Yes No
If so, who?
EDUCATIONAL BACKGROUND
Name and location of school
High School
College
Graduate School
Other
FOR OFFICE USE ONLY
Date Submitted:
Copy Sent to:
Updated 4/15
Course of Study
Did you graduate?
Degree
Independent Living Services, Inc. & Creative Living, Inc.
Application for Employment
Have you ever been convicted of a crime? (Even if your conviction was subsequently expunged or sealed) Yes No Please Explain:
Was the charge confirmed
Have you ever been accused of abuse or neglect? Yes No Yes No Please Explain:
A Valid Driver’s License is required for all direct care positions.
Do you have a valid, State of Arkansas Driver’s License? Yes No Have you been convicted of driving under the influence of alcohol or drugs in the past three years?
Do you have current liability insurance on the vehicle which you drive?
Yes No Yes No CERTIFICATION/TRAINING EXPERIENCE (check those which apply) – Proof may be required upon offer of employment.
____ CPR/First Aid
____ Behavior Management ____ Crisis Prevention/Intervention Training ____ Leadership Training ____ Supervision ____ Word Processing ____ Sign Language
____ Excel/Spread Sheets
____ Other: ___________________
EMPLOYMENT HISTORY (Start with your present or most recent employer then list in reverse order.) Company Name:
Telephone:
Address:
Job Title and Briefly describe your Duties:
Employed (Month and Year)
From: To:
Last Base Rate of Pay
$
Reason for Leaving:
Company Name:
Telephone:
Address:
Job Title and Briefly describe your Duties:
Employed (Month and Year)
From: To:
Last Base Rate of Pay
$
Reason for Leaving:
Company Name:
Telephone:
Address:
Employed (Month and Year)
From: To:
Last Base Rate of Pay
$
Reason for Leaving:
Name of Supervisor:
Name of Supervisor:
Name of Supervisor
Job Title and Briefly describe your Duties:
Updated 4/15
Independent Living Services, Inc. & Creative Living, Inc.
Application for Employment
PERSONAL REFERENCES (List two professional and one personal reference other than family members)
Name
Telephone
Relationship
1.
2.
3.
Are there any employers listed whom you do not want us to contact? Please provide a reason. _____________________________________________________________________________________________________
Your signature indicates we may contact the employers listed above and on any additional sheets of paper unless you indicate otherwise. I certify that the information contained in this application is true, complete and accurate. I further certify that any falsification, misrepresentation, or omission of facts may prevent me being hired, or if hired may subject me to immediate dismissal. During the term of any employment that I may have with Independent Living Services, Inc. and Creative Living, Inc., I will immediately notify the Human Resources Department with written explanation of any facts or circumstances which would cause my answers in this application to change.
Applicant Signature____________________________________ Date ___________________
Partial Conditions of Employment
x Independent Living Services, Inc. & Creative Living, Inc., hereinafter collectively called the Corporation, may make a thorough review of my experience & education and may verify all application and/or interview materials.
x I understand and acknowledge that this application is neither a contract of employment nor a legal document.
x I understand and acknowledge any employment relationship that may result from this application is voluntary on the part of myself and the Corporation. I further acknowledge that either I or the Corporation can terminate the relationship at will, with or without cause, at any time.
x I understand that if I am employed, I am employed “At‐Will”. Either I, Independent Living x Services, Inc. and Creative Living, Inc. may end the employment relationship at any time, or any reason or no reason at all. No representative of Independent Living Services, Inc. and Creaative Living, Inc. has the authority to vary this Agreement. I also agree that nothing in Independent Living Services, Inc. and Creative Living, Incs policies, rules, regulations or handbook changes this relationship. The Corporation may change wages, benefits, and conditions of my employment at any time in its sole, absolute and unfettered discretion.
x If employed, I agree to conform to policies, rules, and regulations of the Corporation, and acknowledge that these policies, rules, and regulations may be changed, interpreted, withdrawn, or added to by the Corporation at any time, at its sole, absolute and unfettered discretion, and without any prior notice to me.
x I acknowledge that my employment may be ended, and any offer of employment, if such is made, may be withdrawn, with or without prior notice, at any time, for any reason at the option of the Corporation or myself.
x I understand that the position I am applying for (if involving direct service responsibilities) may involve implementing crisis prevention and intervention services which may include lifting, pulling, and guiding persons with disabilities against potential resistance. I understand this is a condition of employment and have no reason to believe I cannot implement these or other responsibilities of the position for which I am applying.
x I understand and accept that the needs of the people served by the Corporation may, at times, make the following conditions mandatory: *overtime *shift work *working on holidays *rotating schedule *work schedule other than I was hired for.
x Drug Screening – Some positions within the Corporation require a drug screening. If I will be working in a position that requires drug screening, I agree to submit to a drug test within 48 hours after a job offer is made. I hereby authorize the medical contractor performing the test to provide Independent Living Services a complete record and report. I understand that my conditional offer of employment is subject to obtaining of negative results on said drug screen. (If you do not take the test within 48 hours of the job offer or do not stay to complete the tests, your offer of employment may be rescinded and you may not be eligible for employment with Independent Living Services.)
Applicant Signature ____________________________________ Date ___________________
Updated 4/15
Independent Living Services, Inc. & Creative Living, Inc.
Application for Employment
RELEASE FOR BACKGROUND INVESTIGATION
I hereby give Independent Living Services, Inc. & Creative Living, Inc. permission to do a criminal records check, adult abuse registry check, child abuse registry check, and traffic violation record. I further understand employment with Independent Living Services, Inc. & Creative Living, Inc., is contingent upon results of criminal record checks adult abuse registry check, child abuse registry check, and traffic violation record. I understand a conviction of a crime may be a condition for termination of employment or withdrawal of an offer of employment. By my signature below, I agree to release and hold harmless Independent Living Services & Creative Living, Inc. hereinafter collectively called the Corporation, from any claims I might have based on decisions made by the Corporation with regard to my employment resulting from results received from the criminal records check, adult abuse registry check, child abuse registry check or traffic violation record check. Applicant Signature____________________________________ Date ___________________
Applicant Printed Name: _________________________________________
Applicant Social Security Number: _________________________________
Date: _________________________
I acknowledge that I have made application with Independent Living Services & Creative Living of Arkansas. I hereby give consent to any and all prior employers to provide information to Independent Living Services with regard to my employment. I also give consent to any personal reference to provide a character reference to Independent Living Services. I authorize any DDS or Long Term Care facility to release information to Independent Living Services about my previous employment, even if the facility is not listed on my application.
Applicant Signature____________________________________ Date ___________________
This consent is valid for a period of six (6) months from the date indicated above.
A copy of this form shall serve as an original.
Instructions to Current/Former Employer
The individual named above has applied for employment with Independent Living Services, Inc. & Creative Living, Inc. Please respond candidly to the requests for information listed below and return your written responses via either facsimile or U.S. Mail. This Consent and Release is intended to comply with Ark. Cod Ann. §11‐3‐204 of law providing current and former employers with protection for providing job information about current or former employees to prospective employers.
Please return the information to: Independent Living Services, Inc.
Human Resources
615 E. Robins
Conway, AR 72032
By Mail:
P. O. Box 1070
Conway, AR 72033
Facsimile: 501 548‐6432
Updated 4/15
Independent Living Services & Creative Living
Application for Employment
Employment / Personal Reference Form
For Administrative Use – Applicant Does Not Complete this Page
Individual completing reference check please complete the following:
References Checked by
Person Completing checks:
Personal Reference
Name of Reference: Date Checked:
How many years have you known the applicant?
How do you know the applicant?
Do you believe the applicant to be reliable?
Is there any reason they would not be well suited to work with people with disabilities?
If you responded in the affirmative to the above question, please provide an explanation on a separate sheet of paper.
Do you feel this applicant would be a valuable asset to our agency?
Employment Reference
Employer Name: Date Checked:
Individual Giving Reference: Job Title:
1. Please verify the following information given to us by the applicant to see if it is correct.
Employment Information
Correct
Incorrect If incorrect, please provide correct information
Employment Dates:
Job Title:
Reason for Leaving:
2. How would you rate this individual on the following?
Outstanding
Above Average
Average
Below Average
Ability
Dependability
Work Quality
Flexibility
Attendance
3. Is this person eligible for rehire with your company? Employment Reference
Employer Name: Date Checked:
Individual Giving Reference: Job Title:
1. Please verify the following information given to us by the applicant to see if it is correct.
Employment Information
Correct
Incorrect If incorrect, please provide correct information
Employment Dates:
Job Title:
Reason for Leaving:
2. How would you rate this individual on the following?
Outstanding
Above Average
Average
Below Average
Ability
Dependability
Work Quality
Flexibility
Attendance
3. Is this person eligible for rehire with your company? Please return the information to:
Updated 4/15
Independent Living Services, Inc.
Human Resources
P. O. Box 1070
Conway, AR 72033
Phone: 501 327‐5234 x 321
Facsimile: 501 358‐6059