APPLICATION FOR EMPLOYMENT
The mission of Charles Hall Youth Services is to assist at-risk youth
in making a successful transition from troubled adolescence to mature adulthood.
Please Note: You must be at least 21 years of age AND able to pass criminal history and child abuse & neglect background checks to be employed with Charles Hall Youth Services.
PERSONAL INFORMATION Date of Application: ______
Name: ______
First MI Last
Email Address:______
Street Address: ______
City, State, Zip: ______
Phone Number/s: ______Best time for us to call you: ______
Are you 21 years of age? ______Social Security Number: ______
In case of an emergency, who should be notified? ______
Relationship: ______Address:______
City: ______State: ______Phone Number: ______
Are you a U.S. citizen? Yes☐ No☐
Do you have a current, valid driver’s license? Yes☐ No☐
Are you prevented from lawfully becoming employed in this country because of your Visa or immigration status? Yes☐ No☐
Have you lived in North Dakota for the past 5 years? Yes☐ No☐
Have you ever been arrested or convicted of a crime? Yes☐ No☐
If yes, please provide details: ______
______
DESIRED EMPLOYMENT
Position applying for: House Manager☐ Residential Life Coach☐ Tutor☐
Other☐ Please explain: ______
Are you employed now? Yes☐ No☐ If so, may we contact your employer?______
If hired, on what date will you be available to start? Click here to enter a date.
Preferred Status: Full-time☐ Part-time☐ Substitute☐
What is the lowest entrance salary you will accept? $______
Place an X in the boxes below, indicating which days and shifts you are willing to work.
/ Sun. / Mon. / Tues. / Wed. / Thurs. / Fri. / Sat. /Days / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Evenings / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Overnights / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Have you ever applied at our agency before? ______If so, when? ______
How did you hear about Charles Hall Youth Services? ______
EDUCATION
Educational Level / Name/Location of School / Years Completed / Did you graduate? / Subject Studied / Degree Received /High School / Click here to enter text. / Click here to enter text. / Choose an item. / Click here to enter text.
Junior College / Click here to enter text. / Click here to enter text. / Choose an item. / Click here to enter text.
University / Click here to enter text. / Click here to enter text. / Choose an item. / Click here to enter text.
Graduate School / Click here to enter text. / Click here to enter text. / Choose an item. / Click here to enter text.
Trade, Business, Correspondence / Click here to enter text. / Click here to enter text. / Choose an item. / Click here to enter text.
Licenses and certificates:______
Additional training and special skills:______
______
MILITARY
Were you in U.S. Armed Forces? Yes☐ No☐ If yes, what branch? ______
Dates of duty: From______To______Rank at discharge:______
EMPLOYMENT HISTORY
Please start with your current or most recent employer and work your way backwards.
(1) Employer: ______
Address: ______
Dates of employment: From ______To______
Job Title: ______Hours/Week: ______Salary: $______
Specific job duties: ______
______
Were you ever disciplined in this position (i.e., write-up or warning)? Yes☐ No☐
Reason for Leaving: ______
Supervisor: ______Phone number: ______
* * * * * * * * * * * * *
(2) Employer: ______
Address: ______
Dates of employment: From ______To______
Job Title: ______Hours/Week: ______Salary: $______
Specific job duties: ______
______
Were you ever disciplined in this position (i.e., write-up or warning)? Yes☐ No☐
Reason for Leaving: ______
Supervisor: ______Phone number: ______
* * * * * * * * * * * * *
(3) Employer: ______
Address: ______
Dates of employment: From ______To______
Job Title: ______Hours/Week: ______Salary: $______
Specific job duties: ______
______
Were you ever disciplined in this position (i.e., write-up or warning)? Yes☐ No☐
Reason for Leaving: ______
Supervisor: ______Phone number: ______
* * * * * * * * * * * * *
(4) Employer: ______
Address: ______
Dates of employment: From ______To______
Job Title: ______Hours/Week: ______Salary: $______
Specific job duties: ______
______
Were you ever disciplined in this position (i.e., write-up or warning)? Yes☐ No☐
Reason for Leaving: ______
Supervisor: ______Phone number: ______
REFERENCES
List three professional references, other than relatives, who can accurately attest to your work abilities.
(1) Name: ______Phone Number: ______
Occupation: ______Employer: ______
Relationship to you: ______Years acquainted: ______
Address: ______City: ______State: ______Zip: ______
(2) Name: ______Phone Number: ______
Occupation: ______Employer: ______
Relationship to you: ______Years acquainted: ______
Address: ______City: ______State: ______Zip: ______
(3) Name: ______Phone Number: ______
Occupation: ______Employer: ______
Relationship to you: ______Years acquainted: ______
Address: ______City: ______State: ______Zip: ______
I hereby authorize a check of my background to determine if I am properly qualified for employment with Charles Hall Youth Services. This check would include, but not be limited to: 1) personal references; 2) former employers; 3) Police and Sheriff’s Departments; 4) Motor Vehicle Departments; and 5) Human Service agencies.
I release Charles Hall Youth Services, my references, former employers, and the aforementioned agencies from any and all claims, liabilities and/or litigation arising from a background investigation.
I certify that all the information submitted by me on this application is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I an employed, my employment may be terminated at any time.
In consideration of my employment, I agree to conform to the agency's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, either at my or the agency's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the agency.
______
Signature Date
Application Questionnaire
Please provide brief answers to the questions below.
1. What prompted you to apply for this position, and why do you feel qualified?
2. List three words that best describe you, and explain how these descriptors would affect the position you are applying for.
3. Based on your experiences, what do you think facilitates change in youth?
4. How do you think an unruly child differs from the typical “kid next door”?
5. What type of time commitment are you willing to make to Charles Hall Youth Services?
Applicant Signature: ______Date: ______
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2016 TC