DOUGLASS COMMUNITY SERVICES, INC.

711 Grand Ave.

Hannibal, MO 63401

573-221-3892 (fax 573-221-6196)

Application for Employment

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the agency.

Applicant name:____________________________________________________Date:________

Position(s) applied for or type of work desired:________________________________________

Address:______________________________________________________________________

City:______________________ State: ______________ County:___________ Zip: _________

Telephone #:_________________________Social Security #____________________________

Type of employment desired: _______full-time ______ part-time ______temporary

Date you will be available to start work:_____________________________________________

Have you ever been previously employed by our organization? _____Yes _____No

Are you currently a parent or guardian of a Head Start or Early Head Start student?

_____Yes _____No

Can you submit proof of legal employment authorization & identity? _____Yes _____No

Have you ever been convicted of a crime? _____Yes _____No

If yes, please explain: Answering “yes” to these questions 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.

____________________________________________________________________________________________

How were you referred to us? ______________________________________________________________

Educational History

List school name and location, years completed, course of study, and any degrees earned:

High school:______________________________ Graduated: Yes: _____ No: _______

College(s):_____________________________ Degree Earned:__________________________

Technical Training:______________________________________________________________

Other:________________________________________________________________________

Employment History

Please provide all employment information for your past four employers starting with the most recent.

Employer:___________________________________________Position held:______________

Address:_________________________________________________Telephone #___________

Immediate supervisor and title:_____________________________________________________

May we contact supervisor: yes_________ no ___________

Dates employed: from__________ to _________ Salary:________________________________

Job summary:__________________________________________________________________

Reason for leaving:______________________________________________________________

Employer:___________________________________________Position held:______________

Address:_________________________________________________Telephone #___________

Immediate supervisor and title:_____________________________________________________

May we contact supervisor: yes_________ no ___________

Dates employed: from__________ to _________ Salary:________________________________

Job summary:__________________________________________________________________

Reason for leaving:______________________________________________________________

Employer:___________________________________________Position held:______________

Address:_________________________________________________Telephone #___________

Immediate supervisor and title:_____________________________________________________

May we contact supervisor: yes_________ no ___________

Dates employed: from__________ to _________ Salary:________________________________

Job summary:__________________________________________________________________

Reason for leaving:______________________________________________________________

Employer:___________________________________________Position held:______________

Address:_________________________________________________Telephone #___________

Immediate supervisor and title:_____________________________________________________

May we contact supervisor: yes_________ no ___________

Dates employed: from__________ to _________ Salary:________________________________

Job summary:__________________________________________________________________

Reason for leaving:______________________________________________________________

Other Skills and Qualifications

Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:

______________________________________________________________________________

______________________________________________________________________________

References

List 3 references names, telephone numbers, and years known (do not include relatives):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I hereby authorize Douglass Community Services, Inc. to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or Douglass Community Services, Inc. can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of Douglass Community Services, Inc. not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

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 to reapply and fill out a new application.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant signature:__________________________________________ Date: _____________