Clone 2025 Application for Employment

Promise House Application for Employment
Date of Application*

MonthDayYear
Date
Position Applying For*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
SSN #*
ex. 987-65-4321
Date Of Birth*

YearMonthDay
Date
Email*
example@example.com
Are you at least 18 years of age?*

YesNo
Are you at least 16 years of age?*

YesNo
If less than 16 do you have a work permit?*

YesNo
Have you ever been employed here before?*

YesNo
If yes, give a date.*

MonthDayYear
Date
Are you employed now?*

YesNo
May we contact your current employer?*

YesNo
Can you, if hired, submit verification of your legal right to work in U.S.?

YesNo
If hired, you will be required to submit documents sufficient to establish employment authorization & identify compliance with the immigration reform and control act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired.
On what date would you be available for work?*

YearMonthDay
Date
Expected Salary*
Work Schedule Availability*

Full-TimePart-Time
If temporary, what days?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
If temporary, what hours?

DaysEveningsOvernightsOther
Are you on a lay off and subject to recall?*

YesNo
Give name, address, and telephone number of three references who are not related to you and are not previous employers.
Have you ever been convicted of a crime in this state of any other?*

YesNo
Do you have a record of founded child or dependent adult abuse?*

YesNo
I have been informed by hiring personnel that an Iowa criminal history/dependent adult abuse check will be conducted prior to hiring. I have also been infomred that my Nursing/C.N.A. license will be verified at this time. By signing my signature below, I give permission to Promise House Hiawatha to perform this check.
Signature*

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Signature
Date*

YearMonthDay
Date

Education Level

	Name & Address of School	Course of Study	Years Completed	Diploma /Degree
High School
Undergraduate College
Graduate Professional
Other (Specify)

Employment Experience

Start with your present or last job. 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 status
Employer (Employer 1)
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Job Title
Supervisor
Reason for Leaving
Employer Start Date

MonthDayYear
Date
Employer End Date

MonthDayYear
Date
Work Performed
Starting Wage
Ending Wage
Employer (Employer 2)
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Job Title
Supervisor
Reason for Leaving
Employer Start Date

MonthDayYear
Date
Employer End Date

MonthDayYear
Date
Work Performed
Starting Wage
Ending Wage
Employer (Employer 3)
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Job Title
Supervisor
Reason for Leaving
Employer Start Date

MonthDayYear
Date
Employer End Date

MonthDayYear
Date
Work Performed
Starting Wage
Ending Wage
Additional Information
State any additional information you feel may be helpful to us in considering your application. Summarize special job-related skills & qualifications from employment or other experience
Signature*

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Date*

MonthDayYear
Date
Iowa Health Care Facility (135C) Record Check

Form C
Name*

First NameMiddle NameLast Name
Maiden Name
Date of Birth*

MonthDayYear
Date
Sex*
Social Security Number*
Signature of Requestor

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Waiver

By signing below, I herby give permission for the above requesting official to conduct an Iowa history check with the Division of Criminal Investigation.
Initial Signature*

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Date*

MonthDayYear
Date
Resume Upload

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Promise House Application for Employment

Employment Experience

Iowa Health Care Facility (135C) Record Check

Waiver