Pioneer Center for Human Services

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Spreadsheet

Presentation

4001 Dayton Street
McHenry, IL 60050
Phone: (815) 344-1230
Fax: (815) 344-3815

Download the application (download now) and fax back to us at: (815) 344-3815 or fill out the application below online

Name

Social Security Number

Address (street, city, ST, zip)

Other Phone:

Telephone

Position Applied for

Date of Application

Referral Source

Name of Source (if applicable)

If necessary, best time to reach you at home Please include AM or PM

May we contact you at work? Yes No ,

If Yes, work number and best time to call

If you are under 18 and it is required, can you furnish a work permit? Yes No ,

If No, please explain

Have you submitted an application before? Yes No ,
If Yes, give postion and
Dates

Have you ever been employed here before? Yes No ,
If Yes, give Dates

Are you legally eligible for employment in this country? Yes No

Date available for work?

What is your desired salary range or hourly rate of pay? $

Type of employment desired:
Full-time Part-time Educational Co-Op Seasonal Temporary

Will you relocate if job requires it? Yes No

Will you travel if job requires it? Yes No

If you have reviewed the job description or spoken with Human Resources, are you able to meet the attendance requirements of the position?
Yes No N/A

Will you work overtime if required? Yes No
If No, please explain

Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodations)?
Yes No Need more information about the job's "essential functions" to respond

This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later time to the extent permitted by law.

Driver's License number required if driving may be required in the job for which you are applying
D.L.# State

Have you ever been bonded? Yes No

Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime? Yes No

If yes, please provide date(s) and details

Employment History
Starting with your most recent employer, provide the following information.

Employer	Employer phone:	Dates Employed	from to
Street Address	City State	Compensation (Starting) Hourly Salary	$ per
Starting job title/Final job title		Commission/Bonus/Other Compensation	$
Immediate Supervisor and title (for most recent position May we contact for reference? Yes No Later		Compensation (Final) Hourly Salary	$ per
Why did you leave?		Commission/Bonus/Other Compensation	$
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?

Employer	Employer phone:	Dates Employed	from to
Street Address	City State	Compensation (Starting) Hourly Salary	$ per
Starting job title/Final job title		Commission/Bonus/Other Compensation	$
Immediate Supervisor and title (for most recent position May we contact for reference? Yes No Later		Compensation (Final) Hourly Salary	$ per
Why did you leave?		Commission/Bonus/Other Compensation	$
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?

Employer	Employer phone:	Dates Employed	from to
Street Address	City State	Compensation (Starting) Hourly Salary	$ per
Starting job title/Final job title		Commission/Bonus/Other Compensation	$
Immediate Supervisor and title (for most recent position May we contact for reference? Yes No Later		Compensation (Final) Hourly Salary	$ per
Why did you leave?		Commission/Bonus/Other Compensation	$
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?

Employer	Employer phone:	Dates Employed	from to
Street Address	City State	Compensation (Starting) Hourly Salary	$ per
Starting job title/Final job title		Commission/Bonus/Other Compensation	$
Immediate Supervisor and title (for most recent position May we contact for reference? Yes No Later		Compensation (Final) Hourly Salary	$ per
Why did you leave?		Commission/Bonus/Other Compensation	$
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?

Employment History (continued)
Explain any gaps in your employment, other than those due to personal illness, injury, or disability

If not addressed in previous question, have you ever been fired or asked to resign from a job? Yes No
Explain below.

Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying

Computer Skills (Check appropriate boxes. Include software titles and years of experience.)

Educational Background
Starting with your most recent school attended, provide the following information.

School (incl. City & State)	Years Completed	Level Completed Diploma/Degree/GED/Certification/Other	GPA	Major/Minor

References
List name and telephone number of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.

Name	Title	Relationship to You	Telephone	# of years known

Related Information
To what job-related organizations (professional, trade, etc.) do you belong?

Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

Organization	Offices held

List special accomplishments, publications, awards, etc.

In your current or a prior job, have you ever written instructions or directions to be followed by employees or customers?

Yes No Not Applicable

Is there any other job-related information you want us to know about you?

Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hearby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant Date

For applicants submitting applications electronically:

By checking this box, I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Affirmative Action Voluntary Information

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invited you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. This information will be used and kept confidential in accordance with applicable laws and regulations.

Male Female

Ethnicity

	White*			Asian*
	Black or African American*			American indian or Alaskan Native*
	Hispanic or Latino			Two or more races*
	Native Hawaiian or Other Pacific Islander*			*Not Hispanic or Latino