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					              Reach For Your Potential
DOWNLOADABLE APPLICATION INSTRUCTIONS: Select the gray boxes to type your answer
(The boxes will expand as needed). For Yes/No questions, click the appropriate box to
mark your answer. Once you have answered all the questions, you can print out this
application. Be sure to read, sign, and date the “Applicant’s Statement” and “Consent
for Release of Information”.

                Return your application materials to the Main Office at:
                          1705 South 1st Avenue, Suite I
                               Iowa City, IA 52240




                     1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983
                         Reach For Your Potential
                       Employment Application 

       We do not discriminate on the bases of race, color, religion, national origin, sex, sexual orientation, 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.



 PLEASE ANSWER EVERY QUESTION COMPLETELY.               This application and any attachments become a part of
 Reach For Your Potential records and will not be returned. Each question should be answered fully and
 accurately. No action can be taken on this application until all questions have been answered. Use blank paper if
 you do not have enough room on this application. In reading and answering the following questions, be aware
 that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related
 information.


  Position(s) Applying For:                                                            Date of Application:




  Last Name:                                First Name:                                Middle Name:

  Address:                                                                             Apt. #:

  City:                                     State:                                     Zip Code:

  Home Phone:                               Other Phone:

  Email (if applicable):




Are you 18 year of age or older? (If you are hired you may be required to submit proof of age)                  Yes      No


If hired, can you furnish proof you are eligible to work in the U.S.?            Yes         No




                    REACH FOR YOUR POTENTIAL IS AN EQUAL OPPORTUNITY EMPLOYER




                               1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                                        1
Background
Have you ever applied at Reach For Your Potential before?
If yes, please indicate when:                                                       Yes       No

Have you ever worked for Reach For Your Potential?
If yes, please indicate when:                                                       Yes       No

Have you ever been convicted of or pleaded guilty to any law violation              Yes       No
(except speeding or parking violations)? If yes, please give details:          (Answering “Yes” does not
                                                                               automatically disqualify you from
                                                                               employment; the nature of the
                                                                               offense, date, and the job for
                                                                               which you are applying for will
                                                                               also be considered.)
Are you now or do you expect to be engaged in any other employment?
If yes, please explain:                                                             Yes       No

For Driving Jobs Only: Do you have a valid driver’s license?
If yes, please indicate DL # and Class of License:                                  Yes       No

For Driving Jobs Only: Have you had your driver’s license suspended
or revoked in the last 3 years? If yes, give details:                               Yes       No




Education / Training
Name of High School Attended:                   Years.         Diploma/Degree/              Subjects
                                                Attended:      Certificate Earned:          Studied/Majors:

Name of College(s) Attended:                    Years.         Diploma/Degree/              Subjects
                                                Attended:      Certificate Earned:          Studied/Majors:

Name of Voc. or Tech. School(s) Attended:       Years.         Diploma/Degree/              Subjects
                                                Attended:      Certificate Earned:          Studied/Majors:

What skills or additional training do you have that are related to the job for which you are applying?




What machines or equipment can you operate that are related to the job for which you are applying?




List professional, trade, business, or civic activities and offices held (exclude labor organizations and
memberships which reveal race, color, religion, national origin, sex, age, disability, or other protected
status):




                          1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                                  2
Employment Experience
Start with your present or most recent employer and list all prior employers. Account for all periods of time
including military service and any periods of unemployment. If self-employed, give firm name and supply
business references. PLEASE GIVE MONTH AND YEAR.

  Name of Employer (most recent or current):                         Job Title(s):

  Address:                                     City/State:          Dates of            Include month &
                                                                    Employment:         year
                                                                    From:               To:
  Telephone (important):                       Fax Number (if available):               Starting Pay:
                                                                                        $
  Supervisor’s Name:                           May we contact for a reference check?    Final Pay:
                                                 Yes       No                           $
  Reason for leaving (or wanting to leave):

  Primary job duties:


  Name of Employer:                                                  Job Title(s):

  Address:                                     City/State:          Dates of            Include month &
                                                                    Employment:         year
                                                                    From:               To:
  Telephone (important):                       Fax Number (if available):               Starting Pay:
                                                                                        $
  Supervisor’s Name:                           May we contact for a reference check?    Final Pay:
                                                 Yes       No                           $
  Reason for leaving:

  Primary job duties:


  Name of Employer:                                                  Job Title(s):

  Address:                                     City/State:          Dates of            Include month &
                                                                    Employment:         year
                                                                    From:               To:
  Telephone (important):                       Fax Number (if available):               Starting Pay:
                                                                                        $
  Supervisor’s Name:                           May we contact for a reference check?    Final Pay:
                                                 Yes       No                           $
  Reason for leaving:

  Primary job duties:




                           1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                          3
Additional Employment History
Name of Employer:                                                  Job Title(s):

Address:                                    City/State:          Dates of           Include month &
                                                                 Employment:        year
                                                                 From:              To:
Telephone (important):                      Fax Number (if available):              Starting Pay:
                                                                                    $
Supervisor’s Name:                          May we contact for a reference check?   Final Pay:
                                              Yes       No                          $
Reason for leaving:

Primary job duties:


Name of Employer:                                                  Job Title(s):

Address:                                    City/State:          Dates of           Include month &
                                                                 Employment:        year
                                                                 From:              To:
Telephone (important):                      Fax Number (if available):              Starting Pay:
                                                                                    $
Supervisor’s Name:                          May we contact for a reference check?   Final Pay:
                                              Yes       No                          $
Reason for leaving:

Primary job duties:




Other Applicant Information
Have you ever worked under any other name?
                                                                                    Yes     No
If yes, please give name(s):
Are you presently employed?
                                                                                    Yes     No
If you are presently employed, may we contact your present employer?
                                                                                    Yes     No
Have you ever been fired from a job or asked to resign?
If yes, please explain:
                                                                                    Yes     No




                         1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                      4
References / Additional Info
Please give three personal references, not relatives or former employers.
 Name:                                                           How do you know this person?


Address:                                   City/State:            Telephone (important):




Name:                                                             How do you know this person?


Address:                                   City/State:            Telephone (important):




Name:                                                             How do you know this person?


Address:                                   City/State:            Telephone (important):



State any additional information you feel may be helpful to us in considering your application:




                          1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                 5
Applicant’s Statement
         BE SURE TO READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I certify that all information provided in this employment application is true and complete. I understand that any
false information or omission may disqualify me from further consideration for employment and may result in
my dismissal if discovered at a later date.

I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters
relating to my background and qualifications. I understand that any investigation conducted may include a
request for employment and educational history, credit reports, consumer reports, investigative consumer
reports, driving record, and criminal history.

I authorize any person, school, current and former employer, consumer reporting agency, and any other
organization or agency to provide information relevant to such investigation and I hereby release all persons and
corporations requesting or supplying information pursuant to such investigation from all liability or
responsibility to me for doing so.

I understand that I have the right to make a written request within a reasonable period of time for complete
disclosure of the nature and scope of any investigation. I further authorize any physician or hospital to release
any information which may be necessary to determine my ability to perform the job for which I am being
considered or any future job in the event that I am hired.

I understand I may be required to successfully pass a drug-screening examination. I hereby consent to a pre-
and/or post-employment drug screen as a condition of being hired or of my continued employment, if required.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT
CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY
DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT
THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY
TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.



I have read, understand, and by my signature consent to these statements.


Applicant’s Signature                                                                 Date




                            1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                                 6
                              Reach For Your Potential
                Consent for Release of Information 
                Please complete the following information for background identification purposes.

Name (As it appears on your driver’s license, social security card and/or I.D. card):

 Last Name                                 First Name                                Middle Name

Indicate any other names you have used, not listed on your employment application or resume (maiden name,
other married names, nicknames, etc.):

List all addresses where you have resided within the past five years. Include the street number, street name,
city, state and zip code.
 Present Address:                                                                    Apt. #:

 City:                                     State:                                    Zip Code:


 Previous Address:                                                                   Apt. #:

 City:                                     State:                                    Zip Code:


 Previous Address:                                                                   Apt. #:

 City:                                     State:                                    Zip Code:


 Previous Address:                                                                   Apt. #:

 City:                                     State:                                    Zip Code:


License Number:                                                          Issuing State:

Social Security Number:                                                  Date of Birth:

In accordance with the Privacy Act (5 U.S.C. 552a), Freedom of Information Act and the Fair Credit Reporting act, I
expressly authorize any person associated with any educational institution, past or present employer (including
federal/state/local governments), any military organizations (federal/state), any law enforcement agency
(federal/state/local), any credit reporting agency, any private/public medical institution or office, or any person who has
personal knowledge of my character, work history, medical history (including drug test results and/or applicable
rehabilitation history) and overall mode of living to release this information to any background agency used by this
company for the purpose of my being considered for employment. I hereby agree to release either company, its
employees, agents and any other persons from any and all liability for damages of whatever kind of nature, whether
known or unknown, which may at any time accrue to me on account of 1) reliance by such persons or entities on the
information submitted in my employment application, 2) reliance by such persons or entities on the information obtained
pursuant to this authorization, 3) compliance with or any attempt to comply with this authorization and 4) termination of
my employment based on information obtained pursuant to this authorization. I hereby authorize a copy of this release to
be as valid as the original.



Signature                                                                         Date

                              1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                                         7
                        Reach For Your Potential
                                Availability Form 


Applicant Name:



Please indicate all shifts that you are able to work by checking the appropriate boxes. If you
want full time status, you need to provide more than 40 hours of availability. You should be
available for twice as many shifts as your want. Remember that only Residential Facilitators
have set schedules; direct care staff do not have set schedules.


            Monday      Tuesday      Wednesday        Thursday         Friday     Saturday   Sunday
8/9am-
3pm
3pm-
10pm
10pm-
8/9am



What is the ideal number of hours you would like to work in a week?

What is the first day you are available to work?

Are you able to work at a location that requires lifting?




I, the undersigned, agree to the above availability. I understand that any changes made to my
availability before my potential date of hire need to be approved by the Human Resources Coordinator.




Signature                                                              Today’s date




                        1705 S. 1st Ave.  Iowa City, IA 52240  (319) 354-2983                     8

				
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