Please complete application below:

Application for Employment with Hills and Dales

Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the application and/or interview process should notify a representative of the Human Resource Department.

PLEASE READ BEFORE COMPLETING:

Complete this application in detail. Do not leave sections blank. Simply write N/A if not applicable.
Legibly print or type your responses, no cursive please.
Resumes may be attached but does not substitute for a completed application.
Submission of an application does not guarantee an interview, rather consideration for open positions.
Hills and Dales hires only U.S. Citizens and Aliens lawfully authorized to work in the United States. All new employees must complete the Federal I-9 form which verifies the person’s identity and employment eligibility.
The FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave. For more information about FMLA please visit https://www.dol.gov/whd/regs/compliance/posters/fmlaen.pdf
Hills and Dales is an Equal Opportunity Employer.

Personal Information

Application Date:

Position Applying for:

Last Name:

First Name:

Middle Name:

Email Address:

Street Address:

City:

State:

Zip Code

Primary Phone Number

Secondary Phone Number

Preferred type of employment (select multiple if applicable):

Full-timePart-timeSeasonal

Preferred shift (select multiple if applicable):

FirstSecondThird

Are you available to work weekends?: YesNo

Have you submitted an application here before?:
YesNo

If Yes, dates:

Have you ever worked here before?
YesNo

If Yes, dates:

Name of Hills & Dales Employee who referred you:

Date available for work:

Do you have a valid driver’s license?
YesNo

What is your desired salary range or hourly rate of pay?

per

How did you hear about this position?:

Access DubuqueSchoolCareer/Job FairWebsiteWalk-inNewspaperEmployeeFacebookOther

Employment Record

Name of Employer:

Employer Address:

Phone Number:

Position Held:

Immediate Supervisor:

Description of Duties:

Reason for Leaving:

Dates of Employment:

to

Final Wage:

Name of Employer:

Employer Address:

Phone Number:

Position Held:

Immediate Supervisor:

Description of Duties:

Reason for Leaving:

Dates of Employment:

to

Final Wage:

Name of Employer:

Employer Address:

Phone Number:

Position Held:

Immediate Supervisor:

Description of Duties:

Reason for Leaving:

Dates of Employment:

to

Final Wage:

May inquiry be made of your present employer regarding your character, qualifications and record of employment?

YesNo

May inquiry be made of your past employer(s) regarding your character, qualifications and record of employment?

YesNo

Education

	Name and Address	Course of Study	Number of Years Completed	Diploma/Degree
High School
Undergraduate College
Graduate Professional
Other

Training

Describe any job related training, specialized training, apprenticeship, skills and extra-curricular activities related to the job you are applying for.

References

List three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you.

Reference 1:

Name:

Phone:

Email:

Title:

Years Known:

Reference 2:

Name:

Phone:

Email:

Title:

Years Known:

Reference 3:

Name:

Phone:

Email:

Title:

Years Known:

Have you ever plead “guilty” or “no contest” to, or been convicted of a crime, in any state, include deferred judgments?:

YesNo

Do you have a record of founded child or dependent adult abuse, in any state?:

YesNo

If yes to either question, please provide date(s) and details:

List any other names, last or first, that you have gone by:

Hills and Dales is licensed by federal and state government regulations for multiple service programs. Regulations governing our facility require that we prohibit the employment of individuals with a conviction or prior employment history of child or client abuse, neglect or mistreatment.

By submitting my application, I understand:

If my application for employment is considered, a check of my background will be conducted to determine if there has been a conviction or prior employment history of child, client or dependent adult abuse, neglect or mistreatment. A criminal record check will also be conducted. A check of the Office of Inspector General’s exclusionary list for Medicaid Fraud may also be completed.
If at any time a conviction or prior employment history of child, client or dependent adult abuse, neglect or mistreatment is discovered, my employment with Hills and Dales may be terminated immediately. I also understand that if at any time it is discovered that I am on the Office of Inspector General’s exclusionary list for Medicaid Fraud, my employment with Hills and Dales may be terminated immediately.
I authorize such checks to be conducted.
I will be required to participate in a drug screening as part of an agency physical only if an offer of employment has been extended.
I understand any offer of employment is contingent on acceptable outcomes of such tests and inquiries as stated above.
I understand that part of my interview may include meeting residents and consumers and that I may observe and hear information that may be confidential during that time. I understand that I am not to share this information with any one.

CERTIFICATION OF APPLICANT

Please read carefully

I HEREBY CERTIFY that this application contains no misrepresentations or falsifications and that the information given by me is true and complete to the best of my knowledge and belief. I am aware, that should an investigation at any time disclose any such misrepresentation or falsification, my application may be rejected and I may be dismissed from my employment with Hills and Dales. I further authorize Hills and Dales to make all necessary and appropriate investigations to verify the information contained herein.

I Accept