Association of Group Homes/Nodaway County Services

ASSOCIATION OF GROUP HOMES/NODAWAY COUNTY SERVICES

P.O. BOX 454 MARYVILLE, MO 64468

(660) 582-7113

APPLICATION FOR EMPLOYMENT

This agency is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, creed, color, age, sex, disability, religion, or national origin.

*A copy of your Social Security Card and H.S. diploma/final transcript/GED is REQUIRED before being hired.*

Date PERSONAL INFORMATION *SS#

Name Date of Birth

Present Address______

Street City State Zip

Phone No. E-Mail______Referred By ___

Do you have the following:

A valid driver’s license? Yes No Current CPR? Yes No

A valid class E license? Yes No Current First Aid? Yes No

Current Med Tech/Level One Med Aid? Yes No

Have charges of abuse/neglect ever been substantiated against you? Yes No

Do you have lifting restrictions? Yes No

I understand that if hired, a Criminal Record Check and a check of the DOA/DMH Employee Disqualification List will be completed, and continued

employment will be contingent upon the results of the findings. Yes No

EMPLOYMENT DESIRED

Position

You may be expected to have at least 2 weekends a month available to work if needed. You may also be expected to work at least 2 holidays. Would you be able to do this? ______Would working a stay awake night shift be of interest to you?______

Is there anything about your driving history that might be a problem?______

Hours Available If applicable, attach your college class schedule.

Date You Can Start Are You Employed Now?

May your Present Employer be called?

EDUCATION

Did you graduate from high school or receive a GED? THIS IS A REQUIREMENT.

Yes No

If currently attending college, what year are you?______

EMPLOYMENT HISTORY: List the last three employers, starting with

most recent.

Name and Address Reason for

Date of Employer Phone# Salary Position Leaving

From

To

From

To

From

To

REFERENCES: Give complete information on three people.

Name Address Business Phone#/E-Mail

In case of Emergency Notify:

Name Phone#

Address

Do you have any prior experience working with someone with a disability?

If so, please explain.

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for may be cause for dismissal. Further, I understand and agree that 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 any previous notice.

PLEASE READ CAREFULLY - By inserting my name (as written above) in the text field below, I certify that the above statements are correct. I understand that any false information (or omissions) in the application, or its supporting documents, will be sufficient grounds for refusal to hire me or termination without notice. I agree that all rules, orders, and regulations of the Board of Regents affecting my employment shall constitute a part of my appointment or employment. I further understand that Northwest Missouri State University has the right to review my education, previous employment, driving and criminal records and other background data.

Northwest Missouri State University is an equal opportunity employer.