Online Employment Application

Name*

Address 1

Address 2

City

State

Zip

Country

Date of Application

Other Names Used

Phone

Other Phone

Email*

High School

Address 1

Address 2

City

State

Zip

Country

Major/Program

Diploma or GED?

College

Address 1

Address 2

City

State

Zip

Country

Major/Program

Degree?

Other

Address 1

Address 2

City

State

Zip

Country

Major/Program

Degree?

Highest Grade Completed

List any employment certification, registrations or licenses (please include date scheduled to expire), also include any professional or civic organizations to which you belong.

Please briefly describe any qualities, experience, interest or special training that would make you a good candidate for the position that you have applied for:

How did you hear about SLI?*

Have you worked for SLI before?

Have you applied at SLI before?

Have you read the entire job description?

Do you believe that you are capable of completing all duties as described in the description?

Position applied for?

Date available for work?

Do you meet the minimum qualifications and requirements for this position?

Experience

1 - Please put most recent employer first. 2 - List four most recent positions. 3 - Include any part-time positions. 4 - Reason for leaving must be completed. 5 - Specify any periods of unemployment.

Most recent job/position?

Most Recent Employer

Address 1

Address 2

City

State

Zip

Country

Phone

Name of Supervisor

May we contact?

Start Date

End Date

Starting Salary

Ending Salary

Job Title/ Duties/ Hours per Week

Exact Reason For Leaving

2nd most recent job/position?

Name of Employer (2)

Address 1

Address 2

City

State

Zip

Country

Phone

Name of Supervisor

May we contact?

Start Date

End Date

Starting Salary

Ending Salary

Job Title/ Duties/ Hours per Week

Exact Reason For Leaving

3rd most recent job/position?

Name of Employer (3)

Address 1

Address 2

City

State

Zip

Country

Phone

Name of Supervisor

May we contact?

Start Date

End Date

Starting Salary

Ending Salary

Job Title/ Duties/ Hours per Week

Exact Reason For Leaving

4th most recent job/position?

Name of Employer (4)

Address 1

Address 2

City

State

Zip

Country

Phone

Name of Supervisor

May we contact?

Start Date

End Date

Starting Salary

Ending Salary

Job Title/ Duties/ Hours per Week

Exact Reason For Leaving

Have you ever been asked to resign from a job?

If Yes, please describe:

Questions of Record

Please list dates and details for any vehicular moving violations (tickets) in the past 36 months - if none, write "none":

Please list dates and details for any vehicular accidents in the past 36 months - if none, write "none":

Please list dates and details if you have had a suspended drivers license in the past 36 months - if none, write "none":

Please provide dates and details for any DUI or DWI during the last 60 months - if none, write "none":

Please provide a description for any felony or misdemeanor conviction - if none, write "none":

Please provide a description for any child abuse or adult abuse committed or confirmed - if none, write "none":

Are you eligible for employment in the United States?

If no, please explain:

Days and times that you are available to commit to a work schedule:

Mon - Fri (From - To)

Saturday (From - To)

Sunday (From - To)

Overnight (From - To)

Days and times not available to work:

Do you have a valid Kansas driver's license?

References

Include individuals directly familiar with your work ability. Please include one close relative. Use phone numbers where references may be reached during weekdays.

Name*

Address 1

Address 2

City

State

Zip

Country

Phone

Years Known & Relationship

Name*

Address 1

Address 2

City

State

Zip

Country

Phone

Years Known & Relationship

Name*

Address 1

Address 2

City

State

Zip

Country

Phone

Years Known & Relationship

Do you have any relatives employed or served by SLI?

Certification and Release

I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize SLI and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to a drug test to detect the use of illegal drugs prior to and during my employment. I understand that all offers of employment will be conditional offers of employment subject to passage of a drug screen, DCF CPS/APS, KDHE and DMV. If I am unable to pass a drug screen DCF CPS/APS, KDHE ot DMV. SLI reserves the right to withdraw the conditional offer of employment whether or not employment has actually begun.

Social Security #

Signature

Date

This release is valid for 12 months following date of release.

SLI does not discriminate on the basis of race, color, religion, nation of origin, ancestry, sex, age, disability or veteran status. Our organization highly values diversity. Inquiries concerning our organization's compliance with equal rights regulations should be directed to the Vice President of Services and Faciliites.

SLI Applicant Authorization to Release Information

I authorize SLI to contact any company, institution, law enforcement agency, state agency, bureau or individual it deems appropriate to investigate my employment history, job performance, background, qualifications, driving record and other relevant information, if job related. I give my full consent for all contacted persons, including former employers, to provide the information concerning this application, I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to the Company.

Name*

Date

Maiden Name and/or other names currently or formerly known by:

Gender

Nationality

Birthdate

Drivers License #

State Drivers License Issued

SLI currently verifies information with:

Kansas Bureau of Investigation
KDADS Nurse Aide Registry
Adult and Child Abuse and Neglect - Department for Children and Families
Motor Vehicle Report
Topeka Municipal Court
KDADS Health Occupations Credentialing
Office of Inspector General
Shawnee County Court Records
KDOC Kansas Adult Supervised Population Electronic Repository
Other local, state and national databases and public information systems

According to the Fair Credit Reporting Act, applicants are entitled to know if insurance or employment is denied because of information obtained by the prospective employer from a consumer-reporting agency.

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