Job Applying For*

Date of Application*

Position applied for*

Referred by*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone(Primary)*

Telephone(Other)*

Are you at least 18 years of age?*

Yes
No

Are you at least 16 years of age?*

Yes
No

If under age 16, can you furnish a work permit?*

Yes
No

Are you presently employed?*

Yes
No

May we contact your present employer?*

Yes
No

Have you ever been employed here before?*

Yes
No

Are you able to perform the job duty with or without accommodations*

Yes
No

If accommodation is required, please identify:*

If hired, you will be required to furnish documents sufficient to establish employment authorization and identity compliance with the Immigration Reform Act of 1986. While you need not provide any proof of citizenship or immigration status at the time you are interviewed, please be prepared to state that you are able to do so immediately upon being hired.

Date available for work*

Expected salary (in $)*

Availability to work:

Full time*

Part time*

PRN*

Do you have a record of founded child and/or dependent adult abuse, or have you been convicted of a crime in this or any other state? If yes, please explain:*

Education:

Degree received

Name (Elementary, Years Completed 5 6 7 8)*

Name (High School, Years Completed 9 10 11 12)*

Name (College/ University , Years Completed 1 2 3 4)*

Name (Grad School, Years Completed 1 2 3 4)*

EMPLOYMENT HISTORY

Begin with your present or last job. Include military service assignments and/or volunteer activities. Account for all periods of unemployment. Exclude names of organizations, which indicate race, color, religion, sex, national origin, or disability.

PLEASE FILL OUT COMPLETELY

Present Employer*

Telephone*

Address of present employer*

Date of Joining*

Date of Relieving*

Duties*

Previous employer*

Telephone*

Address of previous employer*

Date of Joining*

Date of Relieving*

Duties*

Previous employer*

Telephone*

Address of previous employer*

Date of joining*

Date of Relieving*

Duties*

Additional information*

Have you or are you currently working for Grapetree, and/or any other staffing agencies?*

Yes
No

If yes, please provide dates of employment.*

DAVE'S PLACE Reference Release Form

I understand that DAVE'S PLACE will check references, as a party of the hiring process, to learn about my work history. I also understand that these references will be confidential and not disclosed to others. I give permission from the representative of Lexington Square to contact my current employer for a reference.*

Yes
No

I give permission for the representative of DAVE'S PLACE to contact my past employers as shown on my job application, and those listed below for employment references.*

Yes
No

Applicant Signature*

Applicant Print Name*

Date*

DAVE'S PLACE Reference Release Form

I understand that DAVE'S PLACE will check references, as a party of the hiring process, to learn about my work history. I also understand that these references will be confidential and not disclosed to others. I give permission from the representative of Lexington Square to contact my current employer for a reference.*

Yes
No

I give permission for the representative of DAVE'S PLACE to contact my past employers as shown on my job application, and those listed below for employment references.*

Yes
No

Applicant print name*

Applicant signature*

Date*

PLEASE READ CAREFULLY BEFORE SIGNING:

I certify that the information given in this Application for Employment is true and complete to the best of my knowledge. The facility may investigate all statements made in this application. (The facility is required by law to check for any criminal or abuse record.) I understand that any false or misleading information can result in a decision not to hire, or to immediately discharge if already hired; and result in civil and criminal penalties in appropriate cases. I understand my employment references will be checked prior to employment. I understand that this application is NOT a contract of employment; that if hired, regardless of any verbal representations to the contrary, the employment relationship between myself and the facility is terminable at will. I have the right to terminate my employment at any time for any reason, and the facility retains the same right. Any changes to this employment relationship must be in writing. I understand that if I am hired I am required to abide by all rules and regulations established by the facility.

Signature*

Date*

IOWA HEALTHCARE FACILITY (135C) RECORD CHECK FORM C

To: Iowa Division of Criminal Investigation LLC Bureau of Identification
215 East 7 th Street Des Moines IA 50319
Phone: 515-281- 6080 FAX 515-725- 6080

From: Lexington Square
500 Messenger Road
Keokuk, Iowa 52632
Phone: 319-524- 5321 Fax: 319-524- 8642

I am requesting an Iowa Criminal History/Dependent Adult Abuse check on: (Type or print legibly)

Last name*

First name*

Middle name

Date of birth*

Sex*

Male
Female

Signature of applicant*

Social security number*

WAIVER

I hereby give my permission for the above requesting agency to conduct an Iowa criminal history and dependent adult abuse check with the Division of Criminal Investigation.

Signature of applicant*

Date*

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