We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Position(s) applied for:

First Name

Middle Name

Last Name

Address

City

State

Zip

Phone Number

Have you ever been employed with us before?	Yes	No
	If yes, when?
Do you have a valid driver's license?	Yes	No
Do you own a vehicle?	Yes	No
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	No
On what date would you be available for work?
Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify an applicant from employment.)	Yes	No

If yes, please explain

Education

	Name & Address of School	Course of Study	Years Completed	Diploma/Degree
High School				Yes No
Undergraduate College				Yes No
Graduate Professional				Yes No
Other (Specify)				Yes No
Describe any specialized training, apprenticeship, skills, extra-curricular activities, or additional information for consideration.

1.) Please list your first and second choice of possible open positions.

2.) MOST of our part-time position hours are evenings and weekends, please list your available work hours below:

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer Address Phone Job Title Supervisor Reason for Leaving	Dates Employed From To Hourly Rate/Salary Start End	Work Performed

Employer Address Phone Job Title Supervisor Reason for Leaving	Dates Employed From To Hourly Rate/Salary Start End	Work Performed

Employer Address Phone Job Title Supervisor Reason for Leaving	Dates Employed From To Hourly Rate/Salary Start End	Work Performed

References

Please identify one reference of a supervisor from a previous employer.

Reference 1

First Name

Last Name

Phone

Address

City

State

Zip

Reference 2

First Name

Last Name

Phone

Address

City

State

Zip

Reference 3

First Name

Last Name

Phone

Address

City

State

Zip

Availability

Quarter/Semester

Please put an "X" through each time interval that you are unable to work due to your class schedule or other commitment(s).

TIME	Mon	Tue	Wed	Thu	Fri	Sat	Sun
7:00 - 7:30 a.m.
7:30 - 8:00 a.m.
8:00 - 8:30 a.m.
8:30 - 9:00 a.m.
9:00 - 9:30 a.m.
9:30 - 10:00 a.m.
10:00 - 10:30 a.m.
10:30 - 11:00 a.m.
11:00 - 11:30 a.m.
11:30 - 12:00 p.m.
12:00 - 12:30 p.m.
12:30 - 1:00 p.m.
1:00 - 1:30 p.m.
1:30 - 2:00 p.m.
2:00 - 2:30 p.m.
2:30 - 3:00 p.m.
3:00 - 3:30 p.m.
3:30 - 4:00 p.m.
4:00 - 4:30 p.m.
4:30 - 5:00 p.m.
5:00 - 5:30 p.m.
5:30 - 6:00 p.m.
6:00 - 6:30 p.m.
6:30 - 7:00 p.m.
7:00 - 7:30 p.m.
7:30 - 8:00 p.m.
8:00 - 8:30 p.m.
8:30 - 9:00 p.m.
9:00 - 9:30 p.m.
9:30 - 10:00 p.m.
10:00 - 10:30 p.m.
10:30 - 11:00 p.m.

Applicant's Statement

The information that is provided in this application is accurate and complete. I certify that I have provided a true representation of my previous job history, personal qualifications, and other relevant information. I authorize representatives of Home and Community Options, Inc. to investigate information about my application, including references from previous employment or personal references noted.

I understand that Home and Community Options, Inc. will complete a criminal background check, and I authorize the agency to make this inquiry. I further understand that I may be disqualified from employment with the organization if I have a substantiated record of criminal activity that warrants disqualification according to law.

This application for employment is considered active for a period of 60 days. If the applicant wishes to be considered for employment with Home and Community Options, Inc. beyond that period of time, the applicant should request that their application continue to be considered.

Home and Community Options, Inc. has an "at will" relationship with its employees. This means that an employee is not required to work for the agency for any set period of time, and that the Agency is not required to employ an individual for any set period of time. Home and Community Options, Inc. may discharge an employee at any time with or without cause.

I understand that by accepting employment with Home and Community Options, Inc. that I am required to take direction from my supervisors and abide by the policies, procedures, and regulations of the Agency. I also agree to participate in all required orientation and training which is provided to me by the Agency.

I understand that by presenting false or misleading information on my application or during the application process, the management of Home and Community Options, Inc. can take immediate action to disqualify my application or terminate my employment.

Signature of Applicant

Date

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