Application For Employment Form

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G& G Living Centers, Inc.
Application for Employment
PO Box 967
Guttenberg, IA 52052
PLEASE PRINT
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable
accommodation to the application and/or interview process should notify a representative of the Human Resources Dept.
G & G LIVING CENTERS, INC.IS A SMOKE-FREE AGENCY, PURSUANT TO THE IOWA SMOKE FREE AIR ACT OF 2008.
.
POST-OFFER PRE-EMPLOYMENT DRUG SCREEN REQUIRED
Position(s) applied for ____________________________________________ Date of application ______________
Referral Source: _____ Newspaper/Ad
_____ Internet
_____ G & G Employee (list one name only)__________________________________________
_____ Other, please explain________________________________________________________
NAME _______________________________________________________________________________________
LAST
FIRST
MIDDLE
ADDRESS ____________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
PHONE # (
) ________________ Cell phone # (
)_____________ Email Address __________________
If necessary, best time to call you at home is …………………………………………………….. _____:____ am/pm.
May we contact you at work? ……………………………………………………………………………
Yes
No
If yes, work number and best time to call ……..(
)___________________________
_____: ____ am/pm.
Have you submitted an application here before? ………………………………………………………… Yes
No
If yes, give date(s) and position(s) __________________________________________________________________
Have you ever been employed here before?…………….….…………………………………………….. Yes
No
If yes, give dates………………………………………..…………..From _____/_____/_____ To _____/_____/_____
Are you legally eligible for employment in this country? ………………………………………………
Yes
No
Date available for work…………….._____/_____/_____
What is your desired salary range?……..$___________
Type of employment desired: ………….____ Full-Time
____Part-time ____Temporary or Summer employment
Will you relocate if job requires it? …………………………………………………………………….
Yes
No
Are you able to meet the attendance requirements of the position?……………………………………..
Yes
No
Do you have a record of founded child or dependent adult abuse or have you been convicted of a crime in this state or
any other state?…………………………………………………………………………………..………..
Yes
No
If yes, please provide date(s) and details ___________________________________________________________
ANSWERING “YES” TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT. FACTORS SUCH AS DATE OF OFFENSE,
SERIOUSNESS AND NATURE OF THE VIOLATION, REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN INTO ACCOUNT.

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