Employment Application Form

Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Positions Applied For *

Source of Referral

LOCATIONS:

South Bend/Elkhart/Goshen and Near Areas

Michigan City/LaPorte/Valparaiso and Near Areas

Warsaw and Near Areas

HOURS AVAILABLE:

Part Time

7a-3pm

Holidays

Full Time

3pm-11pm

11pm-7am (awake nights)

DAYS AVAILABLE:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

PERSONAL INFORMATION:

Do you hold a valid driver’s license?

Do you own an automobile?

Issuing State

Explain any Traffic Violations you have on your Driving Record in the past three years

Do you have Automobile Liability Insurance IN YOUR NAME as required by State Law?

(If hired for a position, you must provide Proof of Coverage of current insurance (including EXPIRATION DATE and YOUR NAME on the policy)

Are you eligible to work in the U.S.?

Proof will be required upon offer of employment.

List any prior conviction by any local, state, federal or military court of any felony or any other conviction involving sexual crimes, crimes against a person and/or substance abuse.

List any Special Skills, Hobbies, or Interests you have that you think would be beneficial to PARTNERS IN OPPORTUNITIES, INC. and/or this position:

High School Name

High School Location

Address Line 1

City

State

Degree/Area Studied

Graduated ( Yes or No)

College Name

College Location

Address Line 1

City

State

Degree/Area Studied

Graduated ( Yes or No)

Other Name

Other Location

Address Line 1

City

State

Degree/Area Studied

Graduated ( Yes or No)

LIST BELOW PRESENT AND PAST EMPLOYERS BEGINNING WITH THE MOST RECENT

Employer *

Date Started *

Leave Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Job Title *

HOURLY RATE/SALARY

Start

Final

SUPERVISOR

JOB DUTIES AND RESPONSIBILITIES

REASON FOR LEAVING

Employer

Date Started

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

HOURLY RATE/SALARY

Start

Final

SUPERVISOR

JOB DUTIES AND RESPONSIBILITIES

REASON FOR LEAVING

Employer

Date Started

Leave Date

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

HOURLY RATE/SALARY

Start

Final

SUPERVISOR

JOB DUTIES AND RESPONSIBILITIES

REASON FOR LEAVING

Have you ever been employed by Partners in Opportunities, Inc.?

If yes, what positions and dates

List the most recent Supervisor followed by two (2) additional supervisors.

Name *

First

Last

Phone Number *

Relationship *

How Long *

Name *

First

Last

Phone Number *

Relationship *

How Long *

Name

First

Last

Phone Number

Relationship

How Long

I authorize this organization to contact present and previous employers including professional references and to investigate any statements contained in this application. I understand that my driving record will be checked. I further understand that, if interviewed, I will receive the physical requirements for that position and will be asked to verify my ability to perform them. I understand that, upon hire, my hiring and continued employment will be subject to the conditions of employment required by licensing and regulatory agencies and PARTNERS IN OPPORTUNITIES, INC. policy. I also understand that PARTNERS IN OPPORTUNITIES, INC. is an “AT WILL” employer.

I understand that any misrepresentation or omission of material fact on this application form, or in the course of the application process, may prevent me from being hired, or if hired, is cause for immediate termination of employment.

If employed previously by PARTNERS IN OPPORTUNITIES, INC., my former personnel record(s) may be available to the hiring supervisor. The hiring supervisor may also contact any previous PARTNERS IN OPPORTUNITIES, INC. supervisors, should they still be employed by PARTNERS IN OPPORTUNITIES, INC.

Do you Consent? (Yes or No) *

Today's Date *

As an employer subject to government regulations, PARTNERS IN OPPORTUNITIES, INC. is required to collect gender, ethnic group, and veteran status information for applicants and employees. This form is used to provide each applicant an opportunity to Voluntarily furnish such information. All information provided will be used only to comply with the government’s record-keeping requirements. In addition, this information will be kept separate from the employment application and the employee’s personnel file. Such information is considered confidential and will not be used in any hiring decision or for discriminatory purposes.

PARTNERS IN OPPORTUNITIES, INC. is an equal opportunity employer and all employment decisions are made without regard to race, color, religion, national origin, sex, age, disability, veteran status, or any other prohibited basis.

Date

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Positions Applied For

REFERRAL SOURCE

SEX (Male or Female)

Male
Female

PERSONAL INFORMATION:

White: All persons having origins in any of the original people of Europe, North Africa or the Middle East.
Black: All persons having origins in the original people of the Black racial groups of Africa.
Hispanic: All persons Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin.
Asian or Pacific Islander: All persons having origins in any of the original people in the Far East, Southeast Asia, the Pacific Islands, India or Pakistan.
Native American or Alaskan Native: All persons having origins in the original people of North America and who maintain cultural identification through tribal affiliation of community recognition.

Veteran Status:

Vietnam Era Veteran (A person who: (1) Served in the military, ground, naval or air service of the United States on active duty for a period of more than 180 days, and was discharged or released there from with other than a discharge, if any part of such active duty occurred: (I) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (II) between August 5, 1964 and May 7, 1975 in all other cases; or (2) Was discharged or released from active duty for a service connected disability if any part of such active duty was performed: (I) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (II) between August 5, 1964, and May 7, 1975, in all other cases.)
Veteran of Other Campaign (A veteran who served in the military, ground, naval or air service of the United States on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.)
Recently Separated Veteran (Any veteran who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of such veterans’ discharge or release fir active duty.)

To be completed by the applicant—not for interview purposes. To be filed separately from application. This information is used to satisfy the affirmative action requirements of Executive Order 11246 and its implementing regulations.

Find Your Career at PIO

LIST BELOW PRESENT AND PAST EMPLOYERS BEGINNING WITH THE MOST RECENT

List the most recent Supervisor followed by two (2) additional supervisors.

Experience