GENESIS DEVELOPMENT APPLICATION FOR EMPLOYMENT

1 GENESIS DEVELOPMENT . APPLICATION FOR EMPLOYMENT . GENESIS DEVELOPMENT is an Equal Opportunity Educational Institution and EEO/Affirmative Action Employer committed to excellence through diversity. EMPLOYMENT offers are made on the basis of qualifications and without regard to race, sex, religion, national or ethnic origin, disability, age, veteran status, or sexual orientation. DATE OF APPLICATION : _____. Which GENESIS Location(s) are you available to work at? For Office Use Only Adel Belle Plaine Boone Granger Applicant ID.

2 Grinnell Indianola Jefferson Panora Perry Pocahontas Storm Lake Toledo Waukee Winterset Woodward PERSONAL INFORMATION. Name: _____. (Last) (First) (Middle). Address: _____. (Street) (City/State) (Zip Code). Contact Information: _____. (Telephone Number) (E-mail Address). Position(s) Applied For: _____ Available Start Date: _____. Desired Pay Range: _____ Are you currently employed: _____. (Hourly or Salary). Are you available for work? Full-Time Part-Time Temporary PRN. Can you work overtime if the job requires it?

3 Yes No Can you travel if the job requires it? Yes No Have you ever filed an APPLICATION here before: _____. (Date of APPLICATION ). Have you ever been employed here before: _____. Dates Location Position Held Where did you hear of this position: _____. Are you legally eligible for EMPLOYMENT in the USA? Yes No Are you 16 years old or older? Yes No If Yes, Are you 18 or over? Yes No Do you have a valid Drivers' License? Yes No State of Issue:_____. Class of License_____ Endorsements:_____. Have you had any moving violations within the past 3 years?

4 Yes No If Yes, provide detail(s) and date(s):_____. _____. Have you had any automobile accidents within the past 3 years? Yes No If Yes, provide detail(s) and date(s):_____. _____. EDUCATION. Name and Location Graduate? Degree? Major/Subjects of Study High School College or University Specialized Training, Trade School, Other Education Describe your areas of highest proficiency, specialized training, apprenticeships, skills and extracurricular activities: _____. _____. _____. Have you used a different name during your education?

5 Yes No If Yes, provide name and explain:_____. PREVIOUS WORK EXPERIENCE. (Please begin with your most recent employer). Employer:_____ Dates Employed:_____. Employer Address:_____. (Street) (City/State) (Zip Code). Position Held:_____ Supervisor:_____. Reason no longer employed:_____ Final/Current Salary:_____. May we contact this employer: Yes No Duties:_____. _____. _____. Employer:_____ Dates Employed:_____. Employer Address:_____. (Street) (City/State) (Zip Code). Position Held:_____ Supervisor:_____.

6 Reason no longer employed:_____ Final/Current Salary:_____. May we contact this employer: Yes No Duties:_____. _____. _____. Employer:_____ Dates Employed:_____. Employer Address:_____. (Street) (City/State) (Zip Code). Position Held:_____ Supervisor:_____. Reason no longer employed:_____ Final/Current Salary:_____. May we contact this employer: Yes No . Duties:_____. _____. _____. Employer:_____ Dates Employed:_____. Employer Address:_____. (Street) (City/State) (Zip Code). Position Held:_____ Supervisor:_____.

7 Reason no longer employed:_____ Final/Current Salary:_____. May we contact this employer: Yes No Duties:_____. _____. _____. Have you been employed under a different name? Yes No If Yes, provide name and explain:_____. Please describe any breaks in EMPLOYMENT longer than 6 months:_____. _____. _____. Skills and Qualifications: (Summarize special skills and qualifications acquired from EMPLOYMENT or other experiences). _____. _____. _____. Briefly explain why you want to work for GENESIS and what you will bring to the position:_____.

8 _____. _____. _____. _____. _____. REFERENCES. Please list 2 Professional References including; name, mailing address and telephone number _____. _____. _____. Do you have a record or founded child or dependent adult abuse? Yes No Have you ever been convicted of a crime in this state or any other state? Yes No If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s). was/were committed, sentence(s) imposed, and type(s) of rehabilitation:_____.

9 _____. _____. Have the duties of the position(s) been outlined to you? Yes No Can you perform the essential duties of the position with or without reasonable accommodation? Yes No I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this APPLICATION for EMPLOYMENT as may be necessary in arriving at an EMPLOYMENT decision. I understand that this APPLICATION is not and is not intended to be a contract of EMPLOYMENT .

10 In the event of EMPLOYMENT , I understand that false or misleading information given in my APPLICATION or interview (s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the organization. Signature of Applicant Date *All applications will be held for 2 years. This Page for Office Use Only ---------------------------------------- ---------------------------------------- ---------------------------------------- --------------------------- **For Office Use Only**.