Employment Application - Independent Living Center of Kern County

Employment Application

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An Equal Opportunity Employer
Name*
First Last
Home Telephone:*
Cell Phone:
Email:
Address
Street Address City State ZIP Code
Employment Position Desired
Position Applying for :
Salary Desired:

Personal Information
Have you ever applied to or worked for ILCKC before?*
- Yes
- No
IF YES Please Enter Date
MM slash DD slash YYYY
Do you have any friends or relatives working for ILCKC?*
- Yes
- No
If yes, state name(s) and relationship:
Are you at least 18 years old?*
(If under 18, new hire is subject to verification of minimum legal age.)
- Yes
- No
If hired, can you present evidence of your US citizenship or proof of your legal right to live and work in this country?*
- Yes
- No
Are you able to perform the essential functions of the job for which are applying, either with or without reasonable accommodation?*
- Yes
- No
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Education, Training and Experience
Schools Attended/Graduated:*
- High School
- College/University (Highest Degree)
- Vocational School
Name and Address of High School:
Street Address City State / Province / Region ZIP / Postal Code Country
Number of Years Completed:
Did you Graduate?
- Yes
- No
Degree or Diploma
- Yes
- No
Name and Address of College/University (Highest Degree):
Street Address City State / Province / Region ZIP / Postal Code Country
Number of Years Completed:
Did you Graduate?
- Yes
- No
Degree or Diploma
- Yes
- No
Name and Address of Vocational/Business School
Street Address City State / Province / Region ZIP / Postal Code Country
Number of Years Completed:
Did you Graduate?
- Yes
- No
Degree or Diploma
- Yes
- No
Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at ILCKC?*
- Yes
- No
please explain your experience, training, qualifications or skills which you feel make you especially suited for work at ILCKC:
Do you speak, write or read any foreign languages?*
- Yes
- No
If yes, which language(s)?

Employment History
List below all present and past employment starting with your most recent employer (last 10 years). Attach additional pages at the end of the application if necessary.
Are you currently employed?*
- Yes
- No
Name of Current Employer:
Current Employer Address
Street Address City State ZIP Code
Type of Business:
Business Phone Number:
Your Current Supervisor's Name:
Your Current Supervisor’s Name:
May we contact this current Employer?*
- Yes
- No
Your Position and Duties:
Your Position and Duties:
1/30/1999
Date of Hire:

Do you have past employments to add?*
- Yes
- No
Previous Employer Name:
Previous Employer Name:
Street Address:
City:
State:
Zip Code
Type of Business:
Business Phone Number:
Your Supervisor's Name:
Your Supervisor’s Name:
May we contact this Employer?
- Yes
- No
Your Position and Duties:
Your Position and Duties:
1/30/1999 – 4/30/1999
Date of Employment: From “Date” To “Date”
Reason for Leaving:
Reason for Leaving:

Do you have more past employments to add?*
- Yes
- No
Previous Employer Form Continued
Name of Employer:
Street Address:
City:
State:
Zip Code:
Type of Business:
Business Phone Number:
Your Supervisor's Name:
Your Supervisor’s Name:
May we contact this Employer
- Yes
- No
Your Position and Duties:
Your Position and Duties:
1/30/1999 – 4/30/1999
Date of Employment: From “Date” To “Date”
Reason for Leaving:
Reason for Leaving:

Do you have more past employments to add?*
- Yes
- No
Previous Employer Form Continued
Employer Name:
Street Address:
City:
State:
Zip Code:
Type of Business:
Business Phone Number:
Your Supervisor's Name:
Your Supervisor’s Name:
May we contact this Employer
May we contact this Employer
- Yes
- No
Your Position and Duties:
Your Position and Duties:
1/30/1999 – 4/30/1999
Date of Employment: From “Date” To “Date”
Reason for Leaving:
Reason for Leaving:

Do you have more past employments to add?*
- Yes
- No
Previous Employer Form Continued
Employer Name:
Street Address:
City:
State:
Zip Code:
Type of Business:
Business Phone Number:
Your Supervisor's Name:
Your Supervisor’s Name:
May we contact this Employer
May we contact this Employer
- Yes
- No
Your Position and Duties:
Your Position and Duties:
1/30/1999 – 4/30/1999
Date of Employment: From “Date” To “Date”
Reason for Leaving:
Reason for Leaving:

Do you have more past employments to add?*
- Yes
- No
Previous Employer Form Continued
Employer Name:
Street Address:
City:
State:
Zip Code:
Type of Business:
Business Phone Number:
Your Supervisor's Name:
Your Supervisor’s Name:
May we contact this Employer
May we contact this Employer
- Yes
- No
Your Position and Duties:
Your Position and Duties:
1/30/1999 – 4/30/1999
Date of Employment: From “Date” To “Date”
Reason for Leaving:
Reason for Leaving:

Military Service
Are you currently serving in the military?
- Yes
- No
If yes, Please Describe:

References:
List three persons not related to you who have knowledge of your work performance.
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation:
Number of Years Acquainted:

References Continued:
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation:
Number of Years Acquainted:

References Continued:
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Occupation:
Number of Years Acquainted:

Please Read Carefully, Initial Below Each Paragraph:
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.*
I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment, and further authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.*
I understand that nothing contained in the application, or conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create an employment contract between the company and me. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company's designated representative.*
By Entering your First and Last Name you have indicated that you have Read and Initial all the above Terms and Conditions.*
First Last
Date*
MM slash DD slash YYYY

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