Application - Hab Services

HABILITATIVE SERVICES OF NORTH FLORIDA, INC.

APPLICATION FOR EMPLOYMENT

Habilitative Services of North Florida, Inc. is an Equal Opportunity Employer. Accordingly, we promote equal opportunity in the areas of recruitment, employment, training, development, transfer and promotion. Our employment practices are without regard to race, color, religion, sex, gender identity, sexual orientation, age, citizenship, marital status, disability, national origin, veteran status, or any other categories protected by federal, state, and local anti-discrimination laws.

Habilitative Services of North Florida, Inc Application For Employment

Name of Applicant:

Application Date:

Name (Last)

Name (First)

Name (Middle)

Name (Prefer to be called)

Physical Address (Street & No.)

Physical Address (City)

Physical Address (State)

Physical AsZipcode

Mailing Address (Street & No.)

Mailing Address (City)

Mailing Address (State)

Mailing Address (Zipcode)

Telephone # (Home)

Telephone # (Business)

Telephone # (Other)

Best time to contact you at home

Social Security #

Have you previously filed an application with us?

Yes

If yes, give date

Have you previously been employed with us?

Yes

If yes, give date

Are you currently employed?

Yes

Are you currently on layoff and subject to recall?

Yes

Do you have any friends or relatives working here?

Yes

If yes, Name:

Relationship

If hired, when would you be able to start?

If applying for residential services, which shifts are you willing to work? (check all that apply):

1st Shift

2nd Shift

3rd Shift

Sleep-Over

What hours and/or shift(s) would you prefer to work?

What hours and/or shift(s) would you prefer not to work?

Education- High School (School Name/Location)

Education- High School (# Yrs Completed)

Education- High School (Degree)

Education- High School (Study/Major)

Education- College/University (School Name/Location)

Education- College/University (# Yrs Completed)

Education- College/University (Degree)

Education- College/University (Study/Major)

Education- Graduate/Professional (School Name/Location)

Education- Graduate/Professional (# Yrs Completed)

Education- Graduate/Professional (Degree)

Education- Graduate/Professional (Study/Major)

Education- Trade/Correspondence (School Name/Location)

Education- Trade/Correspondence (# Yrs Completed)

Education- Trade/Correspondence (Degree)

Education- Trade/Correspondence (Study/Major)

Education- Other (School Name/Location)

Education- Other (# Yrs Completed)

Education- Other (Degree)

Education- Other (Study/Major)

Do you have a high school diploma or equivalency?

Diploma

GED

Other

If other, please explain:

Please describe any job-related specialized training you have had that is related to the position for which you are applying:

Do you hold any specialized licensure or certification (i.e.-Teacher certification, RN, LPN, CNA, CBA, CPA, etc.)?

Previous Employment- (1) Present/Most Recent Employer Name:

Please list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time including any period of unemployment.

(1) Present/Most Recent Employer Address:

(1) Present/Most Recent Employer Phone:

(1) Present/Most Recent Employer Position:

(1) Present/Most Recent Employer Hours Per Week:

(1) Present/Most Recent Employer From:

(1) Present/Most Recent Employer To:

(1) Present/Most Recent Employer Supervisor:

(1) Present/Most Recent Employer Reason For Leaving:

(1) Present/Most Recent Employer Duties & Responsibilities:

(1) Present/Most Recent Employer Did you leave in good standing, and are you eligible for re-hire?

Yes

Previous Employment- (2) Present/Most Recent Employer Name:

(2) Present/Most Recent Employer Address:

(2) Present/Most Recent Employer Phone:

(2) Present/Most Recent Employer Position:

(2) Present/Most Recent Employer Hours Per Week:

(2) Present/Most Recent Employer From:

(2) Present/Most Recent Employer To:

(2) Present/Most Recent Employer Supervisor:

(2) Present/Most Recent Employer Reason For Leaving:

(2) Present/Most Recent Employer Duties & Responsibilities:

(2) Present/Most Recent Employer Did you leave in good standing, and are you eligible for re-hire?

Yes

Previous Employment- (3) Present/Most Recent Employer Name:

(3) Present/Most Recent Employer Address:

(3) Present/Most Recent Employer Phone:

(3) Present/Most Recent Employer Position:

(3) Present/Most Recent Employer Hours Per Week:

(3) Present/Most Recent Employer From:

(3) Present/Most Recent Employer To:

(3) Present/Most Recent Employer Supervisor:

(3) Present/Most Recent Employer Reason For Leaving:

(3) Present/Most Recent Employer Duties & Responsibilities:

(3) Present/Most Recent Employer Did you leave in good standing, and are you eligible for re-hire?

Yes

Previous Employment- (4) Present/Most Recent Employer Name:

(4) Present/Most Recent Employer Address:

(4) Present/Most Recent Employer Phone:

(4) Present/Most Recent Employer Position:

(4) Present/Most Recent Employer Hours Per Week:

(4) Present/Most Recent Employer From:

(4) Present/Most Recent Employer To:

(4) Present/Most Recent Employer Supervisor:

(4) Present/Most Recent Employer Reason For Leaving:

(4) Present/Most Recent Employer Duties & Responsibilities:

(4) Present/Most Recent Employer Did you leave in good standing, and are you eligible for re-hire?

Yes

Have you ever been discharged or asked to resign from any position?

Yes

If yes, please explain:

Why are you seeking a new position at this time?

Have you ever been subject to an internal investigation for misconduct at any previous employment?

Yes

Please explain fully any gaps in your employment history:

If yes, please explain:

List special knowledge, skills, abilities, and attributes you possess and believe relevant to the position you seek You may also list professional, trade, business activities and offices held or any additional information you feel may be helpful to us in considering your application.

How many jobs have you had in the last 5 years not listed above?

Are you prevented from lawfully becoming employed in this country because of visa or immigration status? (Proof of citizenship or immigration status will be required upon employment.)

Yes

Do you have a valid Florida Driver License?

Yes

If yes, DL #

Do you have dependable transportation?

Yes

Do you have auto liability insurance listing you as a covered driver with minimum coverage of $10,000/$20,000 bodily injury and $10,000 property damage?

Yes

Have you ever pled guilty or "no contest" to a crime, been convicted of a crime, had adjudication withheld, prosecution deferred or do you have any criminal charges pending?

Yes

If "yes", please give dates and details of each:

(1) Personal References- Name