For a printable PDF application, click here

On-Line Application for Employment

We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital status, veteran status, sexual orientation, or any other legally protected status


Date of Application:
Employment at HSA is contingent on a successful completion of a drug test.

Last Name:    Middle Initial:   



Are you at least 18 years of age? (as required under ARSD rules for employnment in our agency)

Best time to contact you is:

 

Have you ever filed an application with us before?   

Do any of your friends or relatives work here?

Were you referred to apply for employment by an employee of Human Service Agency?
If yes, please list person's name:

Have you ever been employed with us before?

Have you ever been convicted of a crime?
(The nature of work may require working with vulnerable individuals and driving company vehicles. A conviction may not result in the denial of employment)

Are you currently employed?

Are you fluent in another language besides english?

Are you willing to work:

How did you learn about us?

If other, please list:

EDUCATION

High School

Name/Address of School

EMPLOYMENT (Start with your present or last job. Include any job-related military service.)

Employer

Address

Telephone Number

Job Title

Supervisor

Dates Employed
Start Date End Date

Hourly Rate/Salary
Starting Ending

Work Performed

Reason for Leaving

 

Employer

Address

Telephone Number

Job Title

Supervisor

Dates Employed
Start Date End Date

Hourly Rate/Salary
Starting Ending

Work Performed

Reason for Leaving

 

Employer

Address

Telephone Number

Job Title

Supervisor

Dates Employed
Start Date End Date

Hourly Rate/Salary
Starting Ending

Work Performed

Reason for Leaving


Professional References

1. Name

Address

Phone Number

Occupation


2. Name

Address

Phone Number

Occupation


3. Name

Address

Phone Number

Occupation


Any additional information you feel may be helpful to us in considering your application?


Applicant's Statement:
I certify that answers given herein are true and complete to the best of my knowledge. I authorize HSA permission to conduct a background check that they believe necessary for my employment with HSA. This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at-will" nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this "at-will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such a change in writing. The Human Service Agency conducts a criminal background check for any applicants working with vulnerable adults and/or children.

In the event of employment, I understand that false or misleading information given on my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of this employer

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