APPLICATION FOR EMPLOYMENT
(AN EQUAL OPPORTUNITY EMPLOYER / ALCOHOL & DRUG FREE WORK PLACE)
"We do not discriminate on the basis of race, color, religion, national origin, sex age or disability.  It is our intention that all qualified
applicants be given equal opportunity and that selection decisions be based on job-related factors"

PERSONAL INFORMATION

Name:    Last First Middle

Social Security Number (Last Four Digits Only):    Are You 18 YRS or Older? Yes  No

Address:   Street City State & Zip

Phone Number:   Home   Cell   Email

SPECIAL QUESTIONS:
THIS INFORMATION IS REQUIRED FOR BONA FIDE OCCUPATIONAL QUALIFICATIONS, OR DICTATED BY NATIONAL SECURITY LAWS, OR IS NEEDED FOR OTHER LEGAL PERMISSIBLE REASONS.

Do you have a valid driver's license? Yes  NO      Drivers License Number

ARE YOU EITHER A UNITED STATES CITIZEN OR AN ALIEN AUTHORIZED TO WORK IN THE UNITED STATES Yes  No

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EMPLOYMENT DESIRED: 

Position              Date You Can Start            Salary Desired  

ARE YOU EMPLOYED NOW Yes  No      If so, may we inquire of your present employer  Yes  No

Have you ever applied to or been employed by ASI Yes  No      Where?    When?

EDUCATION:

High School   # of years Attended   Diploma/Degree   Major/Minor  

College          # of years Attended   Diploma/Degree   Major/Minor

Graduate       # of years Attended   Diploma/Degree   Major/Minor  

Trade, Business,
Correspondence School   # of years Attended   Diploma/Degree   Major/Minor  

*The Age Discrimination Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40
years of age. 

GENERAL:  

Subjects of Special Study, Research or Trainings

U.S. Military or Naval Services    Rank  

Present Membership in National Guard or Reserves

FORMER EMPLOYERS (List below last three employers, starting with last one first)
Month/Day/Year   Name, Address  Salary   Position Reason
(From - To)                                          Phone of Employer                                                                                                  for leaving

Month/Day/Year   Name, Address  Salary   Position Reason
(From - To)                                         Phone of Employer                                                                                                for leaving

REFERENCES:  Give the name of two professional and one individual not related to you whom you have known at least 1 yr.

Name   Address & Phone   Business   Years Acquainted

Name   Address & Phone   Business   Years Acquainted

Name   Address & Phone   Business   Years Acquainted

INCASE OF EMERGENCY NOTIFY:  Name  Address   Phone Number 

LIMITED CRIMINAL HISTORY/STATE NURSES AID REGISTRY
        In accordance W/State regulatory boards Abilities Services, Inc. shall obtain a limited criminal history for each
        employee, officer, or agent involved in the management, administration, or provision of services.
The limited criminal history shall verify that the employee, officer, or agent has not been convicted of the following:
        (1)  A sex crime
        (2)  Exploitation of an endangered adult
        (3)  Failure to report:
                a.  battery, neglect, or exploitation of an endangered adult; or
                b.  abuse or neglect of a child.
        (4)  Theft, if the person's conviction for theft occurred less than ten (10( years before the person's employment application
              date, except as provided in IC 16-27-2-5(a)(5).
        (5)  Murder
        (6)  Voluntary manslaughter
        (7)  Involuntary manslaughter
        (8)  Felony battery
        (9)  A felony offense relating to a controlled substance
A provider shall have a report from the state nurse aid registry of the Indiana state department of health verifying that each employee or agent involved in the management, administration, and provision of services has not had a finding entered into
the state nurse aide registry (Division o Disability, Aging, and Rehabilitation Services, 460 IAC 6-10-5, filed Nov 4, 2002,
12:04 p.m.: 26 IR 768)
** You will not be denied employment solely because of a convicted record, unless the offense is one of those above.
Have you ever pleaded guilty or been convicted of an offense described in this section Yes  No

    Describe

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"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.  I authorize investigation of all statements that herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may regardless of the date of payment of my wages and salary, be terminated at any time, without prior notice."

Date                    Signature   

                                                      Paste your Resume in the Box below

 or continue to fill out Affirmative Action form.  Hit Enter when finished.

INVITATION TO IDENTIFY FOR AFFIRMATIVE ACTION PURPOSES

Our company is an equal opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability, or any other basis prohibited by federal, state, or local law.  No question on this form is intended to secure information to be used for such discrimination.  The company is required by federal regulations to report information as requested below.  Your contribution of this information is completely voluntary and in o way affects the decision regarding your employment opportunity.  The information you provide is strictly confidential and will be maintained separate from you application form.

Applicant Name                    Date 

Position Applied for 

PLEASE CHECK ONE:                                 INDICATE THE APPROPRIATE RACE/ETHNIC GROUP

Male                                                                  Hispanic or Latino

Female                                                               White

                                                                                  Black or African American

                                                                                  Asian

                                                                                  Native Hawaiian or Other Pacific Islander

                                                                                  American Indiana or Alaska Native

                                                                                  Two or More races

HOW WERE YOU REFERRED TO THIS JOB:

  School/College                                               Walk-IN

  Advertisement                                                  Employee Referral   -   Name of Employee

  Search Firm                                                      Other 

  State Job Service

  Government Agency  

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