Heartland for Children Application for Employment

Mission Statement

Improving safety, permanency, and wellbeing for all children in Polk, Highlands & Hardee Counties.
Application for Employment

The employment policies of Heartland for Children are to recruit and hire qualified employees without discrimination because of race, religion, creed, color, age, sex, marital status, national origin, citizenship status, ancestry, disability, veteran status, communication ability, gender identity or expression or sexual orientation and to treat them equally with respect to compensation and opportunities for advancement – including upgrading, promotion and transfer – consistent with individual skills and the needs of Heartland for Children.

Heartland for Children is a drug-free workplace.
Full Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment Desired
Position Applying For*
Type of Position:

Full TimePart Time
Date available for work*

MonthDayYear
Date
Were you previously employed by us?*

YesNoIf yes, give dates
Desired rate of pay*
How did you learn about Heartland for Children?*
By whom were you referred?

For individuals seeking positions with driving responsibilities, please provide your license number, insurance information, and any traffic violations (other than parking tickets), accidents or insurance claims submitted within the last five (5) years.
State
License #
Insurance Company
Traffic Violations
Why are you interested in working for Heartland for Children?*
Educational Data
High School – Diploma / GED*

YesNo
Name & Address of High School*
Years Attended
Please list schools, colleges, universities, grad schools and post-grad schools you attended.
Name & Address of School #2
# of Years Attended (School #2)
Major (School #2)
Degree (School #2)
Date Graduated (School #2)
Name & Address of School #3
# of Years Attended (School #3)
Major (School #3)
Degree (School #3)
Date Graduated (School #3)
Name & Address of School #4
# of Years Attended (School #4)
Major (School #4)
Degree (School #4)
Date Graduated (School #4)
Subject Matter of Thesis and/or Dissertation
Thesis
Dissertation
Fellowships - if a teaching fellowship - name of course taught, if a research fellowship - name area of study:
#1 - Field of Study
#1 - University
#1 - Start & End Date
#1 - Supervisor
#2 - Field of Study
#2 - University
#2 - Start & End Date
#2 - Supervisor
Intership/Residency/Practicum
#1 Name of Agency, Public/Private Clinic, Hospital, School
#1 Responsibilities
#1 Start & End Date
#1 Supervisor
#2 Name of Agency, Public/Private Clinic, Hospital, School
#2 Responsibilities
#2 Start & End Date
#2 Supervisor
List All Professional Licenses and/or Certificates
License/Certificate #1
State Issuing Organization
Number
Date Issued
License/Certificate #2
State Issuing Organization
Number
Date Issued

Previous Employment Record (Previous 5 years if applicable)

Include military service assignments and any verified work performed on a volunteer basis. Exclude organization names which indicate race, color, religion, sex or national origin.

List All Employment, Most Recent First (Please complete section in its entirety. "See Resume" is not acceptable.)
#1 Employer's Name
#1 Employer's Address
#1 Employer's Phone
#1 Start & End Date
#1 Position
#1 Salary
#1 Supervisor
#1 Reason for Leaving
#2 Employer's Name
#2 Employer's Address
#2 Employer's Phone
#2 Start & End Date
#2 Position
#2 Salary
#2 Supervisor
#2 Reason for Leaving
#3 Employer's Name
#1 Employer's Address
#1 Employer's Phone
#1 Start & End Date
#3 Position
#3 Salary
#3 Supervisor
#3 Reason for Leaving
#4 Employer's Name
#4 Employer's Address
#4 Employer's Phone
#4 Start & End Date
#4 Position
#4 Salary
#4 Supervisor
#4 Reason for Leaving
May we contact current and previous employers for references?*

YesNo

Please List 3 Employment/Professional References
Professional Reference #1: Name
Occupation
Phone
Organization
Address
Professional Reference #2: Name
Occupation
Phone
Organization
Address
Professional Reference #3: Name
Occupation
Phone
Organization
Address
Please List 3 Personal References

(Do Not Include Former Employers or Relatives)
Personal Reference #1: Name
Occupation
Phone
Address
Personal Reference #2: Name
Occupation
Phone
Address
Personal Reference #3: Name
Occupation
Phone
Address

List Friends or Relatives Employed by Heartland for Children (including relatives by marriage)
Name #1
Unit/Department
Relationship
Name #2
Unit/Department
Relationship
Name #3
Unit/Department
Relationship
Do you have any plans for continuing your education or training? If so, what are your plans?
Describe any education or training you have received which would be applicable for work with Heartland for Children.
Please Upload Resume

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APPLICANT’S CERTIFICATION AND AGREEMENT
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. I understand that, if any of the information on this Employment Application is found to be false or materially incomplete, I will be disqualified for employment. I further understand that, if I am employed by Heartland for Children, such false or materially incomplete information shall constitute grounds for my dismissal. I further understand that, if employed, I will be an employee at will and that my employment and compensation can be terminated, with or without cause or notice at any time.

I understand that Heartland for Children will perform a background check, including but not limited to the following: criminal background check, child abuse clearance, driving records, and, if pertinent, a check regarding my participation in federal health care programs. I consent to these investigations. I understand that if I was convicted (including a plea of guilty, nolo contendere or no contest) of certain crimes, I may be disqualified from employment pursuant to State law and regulations. In addition, Heartland for Children reserves the right to deny employment if an applicant has a criminal conviction related to the job responsibilities of the position applied for. I am aware that employment is contingent upon the satisfactory results of my reference checks and background checks.

I acknowledge and agree that, if employed, I have the responsibility to immediately report to the Human Resources Department, if I am charged, excluded, suspended, debarred or otherwise ineligible to participate in the federal health care programs, including Medicare and Medicaid. I understand that if charged with a violation or otherwise found ineligible to participate in the federal health care programs that I must be removed from employment with Heartland for Children and may not reapply until the resolution of such charges , criminal action, suspension, or proposed exclusion. By accepting employment, I agree to these conditions.

I understand that, if I am given a conditional offer of employment, I must undergo a drug screening, to be given at Heartland for Children’s expense. I understand and agree that any employment with Heartland for Children is contingent upon the satisfactory results of said screening.

I understand and agree that, if I have not done so already, I will carefully review the job profile and will inform Heartland for Children immediately if I have any concerns about my ability to perform the essential functions of the position for which I am applying – with or without reasonable accommodation. I understand and agree that Heartland for Children reserves the right to require me to demonstrate that I can perform the essential functions of the job with or without reasonable accommodation.

HFC uses E-Verify to verify the employment eligibility of all newly hired employees. Through E-Verify, employers send information from the I-9 Form to the Social Security Administration (SSA) and the Department of Homeland Security to verify that newly hired employees are authorized to work in the United States. HFC will inform the newly hired employee if E-Verify issues a mismatch and provide written instruction for contesting a mismatch. HFC will keep all personal information confidential."

An Equal Opportunity Employer April 2014
Signature

Clear
Date
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Mission Statement

Employment Desired

Personal

Educational Data

APPLICANT’S CERTIFICATION AND AGREEMENT