Application for Employment Employment Application Position Applied for * Date Last Name First Name Middle Initial Mailing Address City State Zip Code Valid Drivers License? Yes No Highest level of Education Completed High School Diploma/GED Associate's Degree Bachelor's Degree Master's Degree Doctorate Degree Certification /Licensure Education Details- Please List NOTE: Please attach a copy of Official Transcripts supporting education and/or licensure at all levels. Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? Yes No Proof of citizenship or Immigration Status will be required upon employment What date would you be available for work? Employment History: Please give accurate and complete information about any full-time or part-time employment starting with your current or most recent job first. Previous Position 1 Dates of employment 1 Previous Employer 1 Employer Address 1 Previous Supervisor 1 Supervisor Telephone 1 Previous Pay Rate 1 Start Previous Pay Rate 1 End May we contact 1 Yes No Responsibilities 1 Reason for Leaving 1 Previous Position 2 Dates of Employment 2 Previous Employer 2 Employer Address 2 Previous Supervisor 2 Supervisor Telephone 2 Previous Pay Rate 2 Start Previous Pay Rate 2 End May We contact 2 Yes No Responsibilities 2 Reason for Leaving 2 Previous Position 3 Dates of Employment 3 Previous Employer 3 Employer Address 3 Previous Supervisor 3 Supervisor Telephone 3 Previous Pay Rate 3 Start Previous Pay Rate 3 End May we contact 3 Yes No Responsibilities 3 Reason for Leaving 3 Special Skills and Qualifications: Summarize special job-related skills and qualifications acquired from employment or other expertise. Are you enrolled in a federally recognized tribe? Yes No Please attach a copy of your enrollment card or Certificate of Indian Blood Applicant's Statement: It is understood and agreed upon that any misrepresentation in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representatives of the Employer has the authority to make any assurance to the contrary. I give the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. This application is currently on file for six (6) months. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application. We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-related medical condition or any other legally protected status. Signature......................................................Date I understand that, my name will be checked against Nebraska Department of Health and Human Services Adult/Child Protective Services Central Registers. A check of these registers is necessary to ensure that I meet provider standards. The purpose of this check will determine if my name is being maintained on either register as a result previous abuse/neglect allegations which have been investigated and have not been determined to be unfounded. To the best of my knowledge, I do not have a conviction or prior history of adult or child abuse/neglect or maltreatment. Neither have I been convicted of a crime involving moral turpitude. I hereby authorize the Nebraska Department of Health and Human Services to release information contained on the Adult of Child Protective Services Central Register including the information that a record has been found to: Omaha Tribe of Nebraska Children & Family Services, PO BOX 429, Macy, NE 68039 Signature of Applicant Date of Birth Printed Name Social Security Number Home Address of Applicant, City, State, and Zip Code Other names used in Past 10 years Other addresses in past 10 years Names of children who have lived with you I voluntarily allow the above named agency to disclose information. No threat or coercive measures have induced me to sign the consent form. Submit If you are human, leave this field blank.
