Job Application Job Application Form Step 1 of 5 20% POSITION INFORMATIONApplication Date:* Date Format: MM slash DD slash YYYY Position LocationSelect One...Main Business OfficeMen's CenterJessie's PlaceRoyal PinesDiscovery ClubsWhere is the position located?Position TitleList the title of the position from the job posting.CONTACT INFORMATIONLast Name:*First Name:*Middle Initial:Street Address:*City:*State:*ZIP Code:*Home Phone:Work Phone:Cell Phone:Email Address: EDUCATIONHigh School Name or GED:From Date:mm/yyyyTo Date:mm/yyyyCollege:From Date:mm/yyyyTo Date:mm/yyyyMajor:Minor:Degree(s) Earned:College:From Date:mm/yyyyTo Date:mm/yyyyMajor:Minor:Degree(s) Earned:College:From Date:mm/yyyyTo Date:mm/yyyyMajor:Minor:Degree(s) Earned:Other (specify):From Date:mm/yyyyTo Date:mm/yyyyMajor:Minor:Degree(s) Earned: EMPLOYMENT HISTORYBegin with most recentName of Employer:Address:PhoneBegan Employment Date:mm/yyyyEnded Employment Date:mm/yyyy or PresentHourly Rate or Salary:Job Title:Status:Full-TimePart-TimeReason for leaving:Duties:May we contact your current employer?YesNoName of Employer 2:Address:PhoneBegan Employment Date:mm/yyyyEnded Employment Date:mm/yyyy or PresentHourly Rate or Salary:Job Title:Status:Full-TimePart-TimeReason for leaving:Duties:Name of Employer 3:Address:PhoneBegan Employment Date:mm/yyyyEnded Employment Date:mm/yyyy or PresentHourly Rate or Salary:Job Title:Status:Full-TimePart-TimeReason for leaving:Duties:Name of Employer 4:Address:PhoneBegan Employment Date:mm/yyyyEnded Employment Date:mm/yyyy or PresentHourly Rate or Salary:Job Title:Status:Full-TimePart-TimeReason for leaving:Duties:Name of Employer 5:Address:PhoneBegan Employment Date:mm/yyyyEnded Employment Date:mm/yyyy or PresentHourly Rate or Salary:Job Title:Status:Full-TimePart-TimeReason for leaving:Duties: ACHIEVEMENTSList any skills, awards, certificates, licenses or professional achievements:REFERENCESPlease list three references, other than relatives, who can provide information verifying qualifications, character or experience:Name and Title:Address:Phone Number:Name and Title:Address:Phone Number:Name and Title:Address:Phone Number:FAMILY RELATIONSHIPSFor the purposes of disclosure, relative includes the following: spouse, dependent, adult child and his or her spouse, parent, spouse's parents, sibling and his or her spouse.Are you a relative of any employee of the Jimmie Hale Mission?*YesNoList the name(s), relationship and employer/position of all relative(s):FELONY CONVICTION(S)Have you ever been convicted of, or pleaded no contest or guilty to, any crime involving theft, dishonesty, violence or sexual misconduct?*YesNoExplain below:CONSENT AGREEMENT:I represent and warrant that the information I have given on this application is complete and true to the best of my knowledge and belief. I further acknowledge that I understand that I must provide documented verification of education, experience and required certifications and/or licensures. I represent and warrant that I have answered fully and truthfully all questions regarding criminal convictions/records. I understand that any offer of employment is contingent upon a satisfactory criminal background investigation and negative drug and alcohol screen test. I hereby authorize The Jimmie Hale Mission and/or its assignee to conduct a criminal background history investigation and drug and alcohol screen test. I understand that in the event a conviction for a felony or any crime involving moral turpitude is found that termination of employment may occur. I understand and agree that my employment will terminate in the event of a positive drug/alcohol screen test. I authorize any testing agency to provide the results of the drug screen test to The Jimmie Hale Mission. I hereby expressly request, and give permission to former employers and any persons who may have pertinent information concerning this application to furnish such information to The Jimmie Hale Mission human resource appointee. I agree to hold such persons harmless, and I do hereby release them from any and all liability for damage of any nature whatsoever for furnishing such information. I understand that failure to provide full and true information on this application may result in disqualification or dismissal.Signature:*Typing your name in this blank will server as your digital signature for the above consent agreementDate of Signature:* Date Format: MM slash DD slash YYYY EQUAL EMPLOYMENT OPPORTUNITY INFORMATIONThe following information is gathered solely for the purpose of reporting data on race and ethnicity to meet federal and state requirements and will not be used to evaluate the applicant's qualifications, suitability or desirability for employment.Last Name:*First Name:*Middle Name:Date of Birth:* Date Format: MM slash DD slash YYYY Social Security Number:*###-##-####Driver's License Number:*Please list two letter state abbreviation if not part of the number. (Ex. AL 123456789)Are you Hispanic/Lationo? (chose only one)YesNoGender:MaleFemaleWhat is your race? (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Have you ever been employed by the Jimmie Hale Mission?YesNoWhat position?Which location/program?Employed from date:mm/yyyyEmployed to date:mm/yyyyHave you ever been a resident or client of the Jimmie Hale Mission?YesNoWhich location/program?Resident from date:mm/yyyyResident to date:mm/yyyyIt is the policy of Jimmie Hale Mission that no person shall, on the basis of race, color, disability, sex, creed, national origin, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or employment. (Jimmie Hale Mission will make reasonable accommodations for qualified disabled applicants or employees.) Upload Resume:Accepted file types: pdf, doc.You may upload your resume (PDF or DOC) hereUpload Any Additional Document:Accepted file types: pdf, doc.(cover letter, certification, license, etc.)Upload Any Additional Document:Accepted file types: pdf, doc.(cover letter, certification, license, etc.) Once you click SUBMIT, please do NOT click the back button, refresh the page or close the tab/window as this can interfere with a proper form submission. If you are also attaching PDF files, the transmission process could take a few minutes depending on file size and your internet connection. Thank you for your patience.NameThis field is for validation purposes and should be left unchanged.
