For a printable PDF application, click here

Position(s) Applying For:

Date of Application:

In order to avoid a potential conflict of interest, HSA does not hire persons who are currently receiving services from HSA. Your signature on this application gives HSA your approval to verify that you are not currently receiving any services. We are required to do a criminal background check. You will need to sign a release giving us permission to do so. Employment at HSA is also contingent on a successful completion of a drug test.

First Name:

Middle Initial:

Last Name:

Street Address/PO Box:

City: State: Zip:

Telephone Number(s):

Email Address:

Best time to contact you at home is: A.M. P.M.

If you have ever been employed under another name, please list:

Have you ever filed an application with us before? Yes No
If yes, give date:

Do any of your friends or relatives work here? Yes No
If yes, give name/relationship/location:

Have you ever been employed with us before? Yes No
If yes, give date/job title/location:

Are you legally eligible to be employed in the United States?
(Proof will be required upon employment) Yes No

Have you ever been convicted of a crime? Yes No
(The nature of work may require working with vulnerable individuals and driving company vehicles. A conviction may not result in the denial of employment)
If yes, please explain:


Can you travel if job requires it? Yes No

Are you currently employed? Yes No

Are you fluent in another language besides english? Yes No
If yes, what languages?

Are you available to work:
Fulltime Part-time Temporary

Are you available to work:
Days Evenings Overnights Any

How did you learn about us? Ad Friend Walk in Employment Agency Relative Other

If other, please list:

EDUCATION

High School

Name/Address of School


Course of Study


Years Completed


Diploma/Degree



Undergraduate School

Name/Address of School


Course of Study


Years Completed


Diploma/Degree



Graduate School

Name/Address of School


Course of Study


Years Completed


Diploma/Degree



Other (Specify)

Name/Address of School


Course of Study


Years Completed


Diploma/Degree

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

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