name What type of employment are you seeking? What times are you available to work? [Day shift (8-5) Swing shift (5-12pm) Night staff (12-8am)
First Name:
Initial:
Last Name:
Social Security Number (Employment Only):
Email:
Street Address
City:
State:
Zip Code:
Phone:
Are you 21 years of age or older? If hired, are you able to provide written documentation that you are authorized to work in the United States? If hired, can you perform the essential functions of the job? If no, please explain:
Odyssey House's Parents and Children's and Adolescent Programs are not permitted to employ persons convicted of felonies or physical or sexual abuse, unless expunged.
Have you ever been convicted of such crimes? If yes, please explain:
Have you ever had a criminal background screening? If yes:
When?
Where?
Result:
Person to notify in case of an emergency:
Name:
Address:
Phone:
Relationship:
References (Non-relative) Name:
Address:
Phone:
Relationship:
Years Known:
Name:
Address:
Phone:
Relationship:
Years Known:
Name:
Address:
Phone:
Relationship:
Years Known:
Education High School:
Name and Location:
Course / Major:
Years Completed:
Diploma / Degree:
Average Grade:
Technical School:
Name and Location:
Course / Major:
Years Completed:
Diploma / Degree:
Average Grade:
College:
Name and Location:
Course / Major:
Years Completed:
Diploma / Degree:
Average Grade:
Other:
Name and Location:
Course / Major:
Years Completed:
Diploma / Degree:
Average Grade:
Professional Certification / License:
Other Job Related Training:
Work Experience (Ten Years) Prior employers will be contacted in most cases. List most recent employment first.
Name of Employer:
Supervisor / Title:
Starting Date:
Ending Date:
Address:
Phone:
Starting / Ending Salary:
Job Title: (List Significant Job Duties)
Reason for Leaving:
Name of Employer
Supervisor / Title:
Starting Date:
Ending Date:
Address:
Phone:
Starting / Ending Salary:
Job Title: (List significant job duties)
Reason for Leaving:
Name of Employer:
Supervisor / Title:
Starting Date:
Ending Date:
Address:
Phone:
Starting / Ending Salary:
Job Title: (List Significant Job Duties)
Reason for Leaving:
Name of Employer:
Supervisor / Title:
Starting Date:
Ending Date:
Address:
Phone:
Starting / Ending Salary:
Job Title: (List significant job duties)
Reason for Leaving:
Are there employers that we should not contact? If yes, which one?
Any other comments about skills or abilities that apply to this job:
Applicant Certification By typing in my name below and entering the date, I certify that I understand and agree that any employment I might be offered by Odyssey House, Inc. (Utah) is "at will" employment, which means my employment will be for no definite period of time and may be terminated at any time and for any lawful reason. I further understand that no person other than the Executive Director of Odyssey House, Inc. has the authority to enter into any legally enforceable employment contract (for a defined time and rate) or make a legally enforceable promise to an employee and, to be enforceable, any contract, promise, or other obligation must be in writing and signed by both the employee and the Executive Director of Odyssey House, Inc.
I understand that Odyssey House, Inc. (Utah) complies with all state and federal laws and statutes as concerns employment discrimination and I may request reasonable accomodation, if needed due to disability, in order to participate in the overall application process. I do not authorize Odyssey House, Inc. (Utah) to release information to outside parties, which may be considered in the hiring decision. I understand that prior convictions, if any, may not necessarily disqualify me for employment, but will be factor, which may be considered in the hiring decision.
I certify that the information in this application is true and complete. I authorize my former employers, references, and other persons or entities identified in this application to release any and all information about me to Odyssey House, Inc. I understand and agree that Odyssey House, Inc. and/or its representatives or third parties may perform an investigation of my employment background that could give reference to my character and general reputation. I release Odyssey House, Inc. and all former employers, references, investigators and other persons from liability from any damage that may result from furnishing information about me oe from my rejection for employment. I understand that I may be subject to a local and national Background and Criminal Investigation as conducted by the Utah Department of Human Services, Office of Licensing or the Department of Corrections in accordance with UCA62A-2-120, 121 and the results of this investigation may impact my potential employment. I understand and agree that any false or misleading informationor any omission of information in this application will subject me to discharge from employment or rejection for employment.
Electronic Signature:
Date: last name
