job-application-form

Quapaw House, Inc.
P.O. Box 3450 * 812 Mountain Pine Road
Hot Springs, Arkansas 71914
(501) 767-4456 * Fax (501) 767-4617
Application For Employment
NAME (Last, First, MI)
Social Security Number
Date of Application
Address (Street, City, State, Zip)
Are you 21 or older?
Home Phone #
Work Phone #
Cell Phone #
Email Address:
Have you ever been employed by QHI?
If yes, when ???
Have you ever applied for a position with QHI?
If yes, when ???
Do you have a valid driver’s license?
Position Applying For:
Salary desired
Date Available :
Shift Preferred :
List relatives employed by QHI
Name
Relationship
Referred by: list name of referral
Employment Disclosure
Please answer all questions as honestly and accurately as possible.
A positive response does not automatically bar you from employment at QHI.
1. Have you ever been convicted of, or pled guilty or no contest, in a domestic
or foreign court to any felony or misdemeanor?
2. Are you presently the subject of any criminal action investigation
or proceeding?
3. Has a court ever denied parental, custodial, or visitation rights as a result of
Child mal-treatment?
If you answered “Yes” to any question(s), please provide full details below:
Question #
Felony
Misdemeanor
State
Country
Date of conviction/criminal activity
Explanation:
Question #
Felony
Misdemeanor
State
Country
Date of conviction/criminal activity
Explanation:
Question #
Felony
Misdemeanor
State
Country
Date of conviction/criminal activity
Explanation:
Employment Experience
Company name:
Supervisor’s name:
Phone Number:
STARTING DATE:
Starting Position Title:
Starting Salary:
ENDING DATE:
Ending Position Title:
Ending Salary:
Describe your duties and responsibilities:
Explain Reason for Leaving:
May we contact your present employer?
Company name:
Supervisor’s name:
Phone Number:
STARTING DATE:
Starting Position Title:
Starting Salary:
ENDING DATE:
Ending Position Title:
Ending Salary:
Describe your duties and responsibilities:
Explain Reason for Leaving:
May we contact your present employer?
Company name:
Supervisor’s name:
Phone Number:
STARTING DATE:
Starting Position Title:
Starting Salary:
ENDING DATE:
Ending Position Title:
Ending Salary:
Describe your duties and responsibilities:
Explain Reason for Leaving:
May we contact your present employer?
Company name:
Supervisor’s name:
Phone Number:
STARTING DATE:
Starting Position Title:
Starting Salary:
ENDING DATE:
Ending Position Title:
Ending Salary:
Describe your duties and responsibilities:
Explain Reason for Leaving:
May we contact your present employer?
EDUCATION
Name and address of school: Academic Major: Years attended: Graduate? Degree?
High School:
Name, Address, Phone#
Diploma
GED
University, College, or Jr. College:
Name, Address, Phone#
University, College, or Jr. College:
Name, Address, Phone#
University, College, or Jr. College:
Name, Address, Phone#
Technical or vocational school:
Name, Address, Phone#
Professional Designation(s) / License(s)
Skills
Check any of the following skills in which you have had experience. Indicate the number after each skill which best describes your level of experience:
1 = Exposure; 2 = Work Experience; 3 = Proficient
Word
Excel
Powerpoint
Access
Outlook Express
Other Software:
REFERENCES
REQUIRED!!! Provide three (3) individuals not previously listed who have been in a position to objectively evaluate your training, experience and capabilities:
Name: Occupation: Phone: Title/Organization name:
What other information do you want us to know for your application?
Resume


reference letter


Agreement of Applicant



I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of wages and salary, be terminated at any time without prior notice and without cause.

Signature:
Date:
Printed Name:
Captcha Code:
captcha
Please submit resume and reference letters
(if available) with completed application!