APPLICATION FOR EMPLOYMENT
Harmony House
Family Violence Center,
Inc.
Prospective employees will receive consideration without discrimination
because of race, creed, color, sex, age, national origin, handicap, or veteran
status.
Personal
Last Name
First
Middle
Date
Street Address
Home Phone (
Have you ever applied for employment with us?
Cell Phone (
□ Yes □ No
If yes: M/Y
Social Security #
Are you available for full-time work?
Pay Expected
□ No
)
Location:
Position Desired
□ Yes
)
If not, what hours can you work?
Are you legally eligible for employment in the United States?
Will you work overtime if asked?
Are you physically or otherwise unable to perform the duties of the job for which you are
applying?
When will you be able to begin work?
□ Yes □ No
Have you ever been found guilty or been convicted of any criminal act in this state or any state?
□ Yes
(Complete section below)
Date
□ No I have not been found guilty of or been convicted of any criminal act in this state or any state.
City
State
County
Circumstances (identify charges, attach
separate page if necessary)
List any tickets you have received or auto accidents you have been involved in the past five years or write “N/A” (non-applicable).
____________________________________________ ____________________________________________
Ticket/Accident
Date
Ticket/Accident
Date
____________________________________________
Ticket/Accident
Date
____________________________________________
Ticket/Accident
Date
Education
School
Graduate
College
Business/Trade/
Technical
High School
Elementary
Name & Location
Course of Study
No. of Years
Completed
Did you graduate?
Degree or Diploma
Special training or skills (languages, machine operation, etc.)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Membership in Professional or Civic Organizations (Exclude those which may disclose your race, color, religion, or national origin)
Military
Did you serve in the U.S. Armed Forces?
□ Yes □ No
Describe any training relevant to the position for which you are
applying:
If yes, in what branch? ___________________________________
Please give accurate, complete full-time and part-time employment
records. Start with present or most recent employer.
Employment History
Company Name (1)
Address
Name of Supervisor
State Job Title and Describe Your Work
Company Name (2)
Address
Name of Supervisor
State Job Title and Describe Your Work
Company Name (3)
Address
Name of Supervisor
State Job Title and Describe Your Work
Company Name (4)
Address
Name of Supervisor
State Job Title and Describe Your Work
We may contact the employers listed
above unless you indicate those you do
not want us to contact.
Telephone
(
)
Employed (state month & year)
From
Weekly Pay
Start
Reason for Leaving
To
Telephone
(
)
Employed (state month & year)
From
Weekly Pay
Start
Reason for Leaving
To
Telephone
(
)
Employed (state month & year)
From
Weekly Pay
Start
Reason for Leaving
To
Telephone
(
)
Employed (state month & year)
From
Weekly Pay
Start
Reason for Leaving
To
Do Not Contact
Employer Number(s) ___________
Reason:
Last
Last
Last
Last
Acknowledgement of Employment Procedures
I certify that the above information is true and correct to the best of my knowledge.
I understand that a full criminal background check will be run before employment with Harmony House.
I understand that a pre-employment drug test will be run and if hired, I will be on the random drug testing list and must
submit to random drug testing.
The following documents must be presented upon hire: (1) current and valid driver’s license, (2) proof of citizenship or
immigration status (e.g. Social Security card or official birth certificate) and (3) current vehicle insurance.
I have read, understand, and agree with the above statements.
___________________________________________________
Name Printed
___________________________________________________
Signature
____________________________________________
Date
Authorization to Release/Receive Information
Applicant: Complete items A through H
FROM: Harmony House
PO Box 5972
Springfield, MO. 65801
(417) 837-7700 ATTN: Personnel
(417) 837-7707 FAX
TO: 1. ______________________________________
2. ______________________________________
I, (A) ______________________________________, do hereby authorize the release and/or receipt of the
following confidential information in written or verbal form: previous employment verification (dates of
employment, job title, duties, and eligibility for rehire.)
The above information is released for the following purpose and that purpose only, employment at Harmony
House. Any other use is forbidden.
I understand that my records are protected by state and federal law, and cannot be disclosed or re-disclosed without
my written consent unless otherwise provided for by law. I also understand that I may revoke this consent at any time
except to the extent that action has been taken in reliance hereon.
I hereby release any person, educational institution, firm physician, clinic, hospital, or agency from any liability for
information furnished pursuant to this authorization.
SIGNATURE: (B) __________________________________ TODAY’S DATE: (C) _____________________________
PRINT NAME: (D) _________________________________ SOC. SEC. #: (E) ________________________________
DATE OF BIRTH: (F) ________________________________ TELEPHONE #: (G) _____________________________
APPROXIMATE DATES OF EMPLOYMENT: (H) ________________________________________________________
EMPLOYER, COMPLETE THE FOLLOWING AND FAX TO (417) 837-7707
POSITION HELD: _______________________________________________________________________________
TASKS OR SKILLS INVOLVED: _____________________________________________________________________
____________________________________________________________________________________________
DATES OF EMPLOYMENT: FROM_______/______/______ TO ______/______/______
REASON FOR SEPARATION: ______________________________________________________________________
ELIGIBLE FOR REHIRE: YES / NO IF NO, WHY? ________________________________________________________
OTHER COMMENTS: ____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
COMPLETED BY: ____________________________________ TITLE: ______________________________________
PHONE #: _________________________________
THANK YOU FOR YOUR TIME.