Application for Employment Form – NorthStar Special Services, Inc.

Today's Date:

Position Applied for:

Personal Information

Name

First

Middle

Last

Are you 21 years or older?

Yes
No

Address & Contact Information

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address

Employment & Background Information

How did you learn about NSS?

If you answered any option except for NSS Website, please let us know the specific referrer

Have you ever been employed with NSS?

Yes
No

Start Date:

End Date

Position(s)

Why did you leave?

Do you have relatives currently employed by NSS?

Yes
No

Relative's Name

Realationship

Relative's Position

Have you ever been convicted of any crime other than traffic violations?

Yes
No

If yes, please provide information. NSS performs criminal background checks on all employees. Failure to provide complete and accurate information constitutes and could preclude you from employment.

Please enter any crimes you were convicted of here (Charges, Conviction Date, Felony or Misdemeanor, Disposition)

If you have more than one item to enter, please add each on a new line.

If applying for a direct care position, do you have any condition that would preclude you from performing physical restraints if neccesary?

Yes
No
N/A

If a job offer is made, how soon will you be available to work?

Do you have any objections to working overtime?

Yes
No

Can you work overtime without prior notice?

Yes
No

Education

Please list your educational background. Include GED, High School, College and/or Technical & Trade Schools. If a job offer is extended, you will be required to provide educational documentation at time of employment. Please place each new item on a new line.

School Name/Address

# of Years

Grad? Y/N

Yes
No

Degree / Major

Additional Related Training

Include any other training relevant to the position for which you have applied (i.e. CPR, First Aid, DDA, & YIT Training. Med Administration, Computer Skills, and workshops attended. Please include date training was completed and expiration dates if applicable. Please place each new item on a new line.

Training

Date (Month/Year)

Expiration Date

Where Received

Personal References

**Please do not list relatives

Name

Realationship

Occupation

Address

Address Line 1

City

State

Zip Code

Phone

Please enter phone number for day and night if applicable.

Years Known

Name

Realationship

Occupation

Address

Address Line 1

City

State

Zip Code

Phone

Please enter phone number for day and night if applicable.

Years Known

Name

Realationship

Occupation

Address

Address Line 1

City

State

Zip Code

Phone

Please enter phone number for day and night if applicable.

Years Known

Employment History

Please provide a complete and accurate job history for at least the last 6 years, beginning with the most recent. NSS performs employment reference checks on all employees. Failure ti provide complete and accurate information could preclude you from employment with NSS.

Current (or most recent) Employer

Job Title

Supervisor Phone

Employed

Duties

Salary

FT or PT?

Full-Time
Part-Time

If Current, may we contact?

Yes
No

Previous Employer:

Job Title

Supervisor Phone

Employed

Duties

Salary

FT or PT?

Full-Time
Part-Time

Previous Employer:

Job Title

Supervisor Phone

Employed

Duties

Salary

FT or PT?

Full-Time
Part-Time

Statement Regarding Hours of Availability

Name *

Position Applying For

NSS Understands that employees have interests and obligations other that their work. We encourage our employees to pursue family involvement, religious activities and continued education. We realize that it is necessary to work around other obligations such as childcare and other employment.

Therefore, in an effort to make the scheduling process most effective and satisfying for both the employee and the company we are requiring each applicant to submit their exact hours of availability, keeping other interests and obligations in mind.

Sunday Availability:

From

To

Monday Availability:

From

To

Tuesday Availability:

From

To

Wednesday Availabilit:y

From

To

Thursday Availability:

From

To

Friday Availability:

From

To

Saturday Availability:

From

To