Date:
Employee Name
Phone Number:
Street Address:
City:
State: AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
Zip Code:
Current Position:
Current Employee Category: FT PT RP Temp
Length of Service in Current Position:
Total Length of Service with Hills and Dales:
Position Applying For:
Describe Your Qualifications:
Have you ever plead "guilty" or "no contest" to, or been convicted of a crime in any state, including deferred judgements? Yes No
Do you have a record of founded child or dependent adult abuse? Yes No
If yes to either question, please provide date(s) and details:
List any other names that you have gone by:
By submitting this application, I give Hills & Dales permission to complete a criminal and/or child and dependent adult abuse background check.
