1440 West Dunkerton Rd Waterloo, IA 50703

(319) 291-2455

Come Work With Us

First Name

Middle Name (If applicable)

Last Name

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Availability

Days or hours you are UNABLE to work

If your application is considered favorably, on what date will you be available for work?

How did you learn of this position?

List any friends or relatives working for us

Are there any other experiences, skills, or qualifications which you feel would especially fit you for work with juveniles or adults in a mental health crisis?

Have you eve been convicted of any offense in an adult court?

Yes

Education

If YES, give complete details. A conviction will not automaically exlude you from consideration.

Did you Graduate?

Yes

Course of Study

Name and Address of School

Previous Employment list below all present & past employment beginning with most recent

Name, Address, & Phone of Company

From Mo/Yr - To Mo/Yr

Starting Salary

Ending Salary

Name of Supervisor

Reason for Leaving

Name, Address, & Phone of Company

From Mo/Yr - To Mo/Yr

Starting Salary

Ending Salary

Name of Supervisor

Reason for Leaving

Name, Address, & Phone of Company

From Mo/Yr - To Mo/Yr

Starting Salary

Ending Salary

Name of Supervisor

Reason for Leaving

May we contact the employers listed above? If not please indicate which one(s) you do not want us to contact.

Have you ever been dismissed or forced to resgin from any position? If yes please explain.

To Whom it May Concern:

I hereby authorize you or your designee to release employment-related information concerning me to North Iowa Juvenile Detention Service.

I also release any individual, partnership or corporation and their officers, agents and employees from any liability for any damage whatever for issuing such information.

A photostatic copy of this authorization is considered as valid as the original.

Your Signature

Refernces

Please include 3 personal references in the box below. (Name, Occupation, Address & Phone)

Please be sure that all telephone numbers are accurate.

Military Service

Where you in te U.S. Armd Forces?

Yes

If YES, which Branch & Rank at Discharge

Dates of Service (To-From)

Have you taken any training under the G.I. Bill of Right? If YES, what did you take?

I understand that prior to my beginning employment at the North Iowa Juvenile Detention Services, the Code of Iowa and Licensing Standards require clearance from the Child Abuse Registry and the Department of Public Safety and I, therefore, give permission for these confidential investigations. I fully understand that the form used for the Department of Public Safety record check requires my birth date _________________ and maiden name (if applicable) and any alias names I have used in the past or currently. ___________________________________ I understand that records which indicate abuse, neglect or exploitation of children or any crimes of violence will prevent me from being hired to work with juveniles in residence at the detention center or clients at the crisis or subacute center, or if discovered after being hired will constitute reason for termination.

Your Signature

The facts set forth in my application for employment are true and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal.

Any offer of employment is contingent upon a physical examination which clearly finds you able to do the required work. Employment is also contingent upon clearance from the Iowa Division of Criminal Investigation and Iowa Department of Human Services Child and Dependent Adult Abuse Registry.

Just as you have the right to quit a job, this employer has the right to terminate your employment at any time, for any reason.

Thank you! We’ll be in touch.