Together, we can enrich lives.

Conditions of employment are stated at the end of this form. Please read carefully before you sign this application.

Social Security Number:

Present Address:

(Street, City, State, Zip Code)

How Long at Present Address:

Previous Address:

(If less than 5 years at present address)

Best way to contact you:

Are any of your relatives presently employed or receiving services with our agency?

Yes

Have you ever worked for our agency before?

Yes

If yes - Position, title, and dates of employment?

How were you referred?

(Newspaper, Employee Referral, Website, College Posting, Other)

Are you at least 18 years of age?

Yes

Can you, upon employment provide genuine documentation establishing your identity and eligibility to be legally employed in the United States?

Yes

Only U.S. Citizens or Aliens who have legal right to work in the U.S. are eligible for employment with our agency.

Have your ever been discharged from any employment or asked to resign?

Yes

If yes - Please explain:

Do you have a valid/current Illinois state Driver's License?

Yes

Do you have valid/current motor vehicle insurance?

Yes

Have you been convicted of more than three (3) traffic violations in the past year?

Yes

List all traffic violations in the past five (5) years which resulted in a conviction or a guilty plea:

List all at-fault vehicle/traffic accidents in the past five years:

Employment

(Starting with most recent position)

Beginning M/Y:

Ending M/Y:

Address, City, State, Zip Code:

Phone Number:

Job Title:

Description of Job Duties:

Supervisor's Name & Title:

May we contact employer?

Yes

Beginning M/Y:

Ending M/Y:

Address, City, State, Zip Code:

Phone Number:

Job Title:

Description of Job Duties:

Supervisor's Name & Title:

May we contact employer?

Yes

Beginning M/Y:

Ending MY:

Address, City, State, Zip Code:

Phone Number:

Job Title:

Description of Job Duties:

Supervisor's Name & Title:

May we contact employer?

Yes

Beginning M/Y:

Ending M/Y:

Address, City, State, Zip Code:

Phone Number:

Job Title:

Description of Job Duties:

Supervisor's Name & Title:

May we contact employer?

Yes

Name & Address of School:

Last Year Attended:

Major Subject:

Degree:

Yes

N/A

Graduated:

Yes

Name & Address of School:

Last Year Attended:

Major Subject:

Degree:

Yes

N/A

Graduated:

Yes

Name & Address of School:

Last Year Attended:

Major Subject:

Degree:

Yes

N/A

Graduated:

Yes

Additional Experience Or Qualifications

List any of experience, skills or other qualifications, which you believe should be considered in evaluating your qualifications for employment:

Attendance & Punctuality Information

Consistent attendance and punctuality are essential requirements of every job with this agency. Is there anything that would interfere with your regular attendance and punctuality if you were offered a job with the agency?

Yes

If yes - Please explain:

Business or Personal References

(At Least Two Business References)

Name:

Business/Home Phone:

Address, City, State, Zip Code:

Occupational Title/Relationship:

How Long Known:

Name:

Business/Home Phone:

Address, City, State, Zip Code:

Occupational Title/Relationship:

How Long Known:

Name:

Business/Home Phone:

Address, City, State, Zip Code:

Occupational Title/Relationship:

How Long Known:

Type Of Employment:

Part Time

Full Time

Hours Available:

Please list all AM and PM hours available Monday-Sunday.

Are you willing to provide care to individuals such as:

Helping individuals who are unable to toilet themselves:

Yes

Helping individuals who are unable to feed themselves:

Yes

Are you willing to assist individuals that have behavioral challenges if:

There is a possibility that an individual may hit, kick, or bite you:

Yes

If someone exhibits inappropriate sexual behavior or uses profanity:

Yes

Are you willing to assist individuals that have physical challenges by:

Lifting and/or assisting individuals that are non-ambulatory:

Yes

Learning to use mechanical devices to assist individuals:

Yes

Notification & Agreement

Please Read Before Signing

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE, I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding the statement should be directed to the resources department before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of Sparc to afford equal opportunity without regard to age, race, religion, color, sex, national origin, marital status, sexual preference and to afford equal opportunities to disabled veterans, and individuals with a disability, and any other characteristics protected by Federal, State or Local Law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release Sparc from all liability that might result from making an investigation.

If hired, I agree to abide by all of Sparc’s rules and regulations, and understand that, is employed, my employment may be terminated with or without cause, and with or without notice, at any time at the option of either Sparc or me. I further understand that no representation, whether oral or written by any representative representative or agent of Sparc, at any time, can constitute a contract of employment. I understand that Sparc shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent for Sparc has the authority to enter into any agreement for employment for any specific specified period of time or to make any changes any policy, procedure benefit or other term or condition of employment other than in a document signed by the CEO, or to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and hereby grant permission confirm the information supplied by me.

Applicant Signature:

Type in your full name

Date:

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All Other Positions

All Other Positions

Personal

General Information

Employment

Education

Additional Experience Or Qualifications

Attendance & Punctuality Information

Business or Personal References

Position Criteria

Notification & Agreement

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