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Hope Haven Application for Employment
Personal Information
Date*
 
E-Mail:*
First Name:*
Middle Name:*
Last Name:*
Address:*
City:*
State:*
Zip Code:*
Home Phone:*
Cell Phone:

 
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How did you learn about us?:*
   Advertisement
   Friend
   Walk In
   Employment Agency
   Relative
   Other
Date Available to Work:*
 
Postion Applied For:*
Pay Expected:*
Are you available for work:*
Will you work overtime if asked?*
Are you 18 years of age or older?*
   Yes    No 
If no, give age
Have you been employed with us before?*
   Yes    No 
If yes, dates
Supervisor worked for:
Are you currently employed?*
   Yes    No 
May we contact your present employer?*
   Yes    No 
As an applicant, I understand that according to federal law all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identify and U.S. citizen status or, if aliens, their legal authorization to work in the U.S. As a consequence, I understand that any offer of employment would be contingent on my ability to produce the required documentation within the time period required by law.
Are you eligible to work in the USA?*
   Yes    No 
Have current & valid driver`s license?*
   Yes    No 
Reliable vehicle to transport clients?*
   Yes    No 
Have you had more than three(3) moving violations, including ticketed accidents in the past year?
Violations?*
   No
   Yes
If yes, please explain:
Professional License: (RN, LPN, CMA or CNA)
License Type:
License #
State Issued:
Education
High School Name/Location:
Diploma Received:
   Diploma
   Equivalency
   None
College Name/Location:
Degree Earned:
Major/Minor:
College Name/Location:
Degree Earned:
Major/Minor:
Employment History
Start with you present and most recent employer, include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color religion, gender, national origin, disabilities, or other protected class. Please list ALL WORK HISTORY. (Attach additional sheet or resume if necessary).
Name Of Employer:
Address:
City:
State:
Zip Code:
Employed From:
Employed To:
Employer Phone:
Job Title:
Supervisor Name:
Work Performed:
Weekly Pay Start:
Weekly Pay Last:
Reason For Leaving:
Name Of Employer:
Address:
City:
State:
Zip Code:
Employed From:
Employed To:
Employer Phone:
Job Title:
Supervisor Name:
Work Performed:
Weekly Pay Start:
Weekly Pay Last:
Reason For Leaving:
Name Of Employer:
Address:
City:
State:
Zip Code:
Employed From:
Employed To:
Employer Phone:
Job Title:
Supervisor Name:
Work Performed:
Weekly Pay Start:
Weekly Pay Last:
Reason For Leaving:
Please identify and explain any gaps in employment longer than 3 months:
Skills Section
Related Knowledge/Skills:
Professional References
Please list three references that have knowledge of your professional experience. (NO relatives please)
Reference Name:*
Occupation:*
Address:*
Phone:*
Reference Name:*
Occupation:*
Address:*
Phone:*
Reference Name:*
Occupation:*
Address:*
Phone:*
Legal Record
Hope Haven is required by law to conduct a Criminal Record Check as a post-job-offer condition of employment. DO YOU HAVE A RECORD OF FOUNDED CHILD OR DEPENDENT ADULT ABUSE, OR HAVE YOU EVER BEEN CONVICTED OR PLED GUILTY TO A CRIME IN THIS STATE OR ANY OTHER STATE?
CHECK ONE:*
   Yes
   No
Under what name(s)?
If yes, list conviction(s) and disposition(s):
(This is not necessarily a bar to employment.)
PLEASE READ THE INFORMATION BELOW AND TYPE NAME & DATE
Having made application for employment with Hope Haven Area Development Center, I certify that the answers and information this application are true and complete to the best of my knowledge. Desiring them to be informed as to my previous record and character, I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision and release Hope Haven Area Development Center from any and all liability resulting from the investigation. I further understand that any information obtained is confidential and I will not have access to such information.

I hereby understand and acknowledge that any employment with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. Neither the acceptance of this application, the subsequent entry into any type of employment relationship or use of the personnel manuals, benefit plans, the like shall serve to create either an actual or implied contract of employment. It is further understood that his at will employment is specifically acknowledged in writing by an authorized executive of this organization. In the even of employment, I also agree that any falsified information or omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I understand that I am required to abide by all rules and regulations of this organization.

I UNDERSTAND that employment for certain job positions may be conditioned upon successfully passing a post-job-offer medical examination. Essential functions of certain job positions may include physical demands requiring the ability to lift up to twenty five (25) pounds regularly and fifty (50) pounds occasionally.

I authorize a thorough investigation of my past employment and activities, including a credit check, reference check and criminal record check; agree to cooperate in such investigations; and release from all liability or responsibility all persons and corporations requesting or supplying such information.``
Type Your Name*
Type Date*
 
Hope Haven Area Development Center is an Equal Opportunity/Affirmative Action Employer and will consider applicants for all positions without regard to race, color, creed, religion, national origin, age, sex, political belief, or disability.
IOWA HEALTH CARE FACILITY (135C) RECORD CHECK FORM C
To: Iowa Division of Criminal Investigation From: Hope haven Area Development Center
Bureau of Identification (Woodlake Group Home)
Wallace State Office Building 828 N. 7th St.
Des Moines, Iowa 50319 Burlington, IA 52601
Phone: (515) 281-5138 Phone: (319) 753-6701
Fax: (515) 242-6876 Fax: (319) 754-0045

I am requesting an Iowa Criminal History/Child & Dependent Adult Abuse Check on:

PLEASE TYPE ALL NAMES USED:
Last Name*
First Name*
Middle Name*
Last Name (2)
Last Name (Maiden)
Date of Birth*
Sex*
   Male
   Female
Social Security Number*
Current Address*
City*
State:*
Zip*
I hereby give permission for an official of Hope Haven Area Development Center to conduct an Iowa Criminal History and Child & Dependent Adult Abuse check with the Division of Criminal Investigation and Iowa Department of Human Services.
Type Your Name*
Type Your Name*
Type Your Name*
Type Date*
 
CONSUMER REPORT AUTHORIZATION
During the application process and at any time during the tenure of my employment with Hope Haven Area Development Center Corporation, I hereby authorize Choice Point Work Place Solutions Inc., on behalf of Hope Haven Area Development Center Corporation to produce a consumer report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be complied with information from credit bureaus, courts record repositories, departments of motor vehicles, past or personal references and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.
Type Your Name*
Type Date*
 
Current Address*
City*
State:*
Zip*
Date of Birth*
Social Security Number*
Driver License Number*
State Issued:*
In what states have you lived in the past 7 years?*
Resume or Work History Upload
Resume Upload:
 
Voluntary Affirmative Action/Equal Employment Opportunity Information
Hope Haven Area Development Center complies, as required with government regulations, regarding Affirmative Action and Equal Employment Opportunity. In our agency`s effort to comply with government record keeping and other legal obligations, we ask that you voluntarily complete this applicant survey. This survey is not a part of your official application for employment, is separately maintained from applications, and will not be used in any hiring decisions. Hope Haven considers applicants for all positions without regard to race, color, reglition, gender, age, creed, national origin, political belief, sexual orientation, or disability.
Please identify your gender:
   Male    Female 

(To select more than one, please hold down the Control key.)

(To select more than one, please hold down the Control key.)
I am a person with a disability?
   Yes    No 
Type Date
 
Position applied for:
Note to All New or Prospective Employees with Progressive Insurance
It has come to Hope Haven’s attention that Progressive/Nationwide/Allied/Amco insurance companies will not cover employees who “Carry persons or property for compensation or a fee”. Since Hope Haven pays employees both for their time and mileage while transporting clients this clause in the Progressive/Nationwide/Allied/Amco policies language would exclude you as an insured from having any coverage.
To be specific you will not have any personal coverage for Liability to others autos, property or bodily injury. You would also have no coverage for your personal auto.
Hope Haven has done extensive research into this issue and unfortunately there are only 2 options available:
1. Change the auto you are (or could be) using to transport clients in to another insurance company.
2. Change the coverage you have with Progressive/Nationwide/Allied/Amco for the auto used to transport clients to “Business Auto” coverage.
Hope Haven is giving you 60 days from the date of your employment to make this change and notify the Human Resource Department of the change you have made along with proof of a new insurance card. If you have not made a change to your insurance within 60 days of employment it will result automatic resignation from Hope Haven.
We suggest you visit with your personal auto insurance agent for guidelines on this issue. If your agent has any questions or if you purchased your insurance via the internet they can call Hope Haven’s agent Tim Farniok at Two Rivers Insurance Services 319-758-8416. HHADC has also contacted 3 personal lines agents that can be of assistance to you if your Progressive/Nationwide/Allied/Amco agent is unable to be of assistance. They are: Johanna Vantiger with Two Rivers Insurance at 319-758-8414 or Scott Hazel with Hazel Insurance at 319-754-7539 or Matt Rinker with Shelter Insurance at 319-752-3938.
I acknowledge reading and understanding the above information:
Type Signature*
Enter Date*
 
 

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