Apply – Eastern Nebraska Human Services Agency Human Resources

Name*

First Middle Last

Previous Names Used:

Last 4 Digits of Social Security Number*

Address*

Street Address City State ZIP Code

Phone Number*

E-mail Address*

Position*

Education Level*

Degree/Area of Study*

Other*

Please elaborate

General Information

Can you provide documents to prove your citizenship and age?*

Yes
No

If not a U.S. citizen do you legally have the right to remain and work in the U.S.?*

Yes
No

Have you ever worked for this agency?*

Yes
No

Under what name?*

Are any of your relatives employed by this agency?*

Yes
No

Please give names.*

How did you learn about this agency?*

Were you referred by an Agency employee?*

Yes
No

By whom?

Qualifications, Skills and Unpaid Experience

List Qualifications and skills related to the position desired, such as professional or technical licenses, special training, computer skills, etc.*

List any non-paid or volunteer experiences that are relevant to the position applied for.

List any gaps in employment history including an explanation.

Most Recent Employer

Name of Most Recent Employer*

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Job Title*

Duties Performed*

Start Date*

End Date

Currently Employed

Wage with most recent employer*

Reason for leaving*

May we contact current employer?

Yes
No

Second Most Recent Employer

Name of 2nd most recent employer

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Job Title

Duties Performed

Start Date

End Date

Ending Wage

Reason for leaving 2nd most recent employer

Third Most Recent Employer

Name of 3rd Most Recent Employer

Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Job Title

Duties Performed

Start Date

End Date

Ending Wage

Reason for leaving 3rd most recent employer

Do you have a valid driver's license?*

Answering "no" will not necessarily exclude you from employment.

Yes
No

Available for:

Regular Full-time
Regular Part-time
Substitute

Hours you are available to work:*

Select all that apply

Select All
Mornings 6 AM - 8 AM
Days 7 AM - 5 PM
Evenings 2 PM - 10 PM
Overnights 10 PM - 10 AM
Saturdays ALL DAY
Sunday ALL DAY

Desired Wage

Brief Comments

Authorization

I certify that the information provided by me on this application is correct. I understand that the furnishing of any misleading or incorrect information on this application or its attachments will be just cause for termination should I become employed at this company. I hereby give permission to the persons and companies named on this application and its attachments to provide any pertinent information to this company, or its duly authorized representative, except where otherwise indicated. I release said parties from all liability for any damages resulting from issuance of such information. I understand that employment is contingent upon the successful completion of all background and reference checks, whether at the pre-employment stage, or throughout my employment, and that I am to notify ENHSA’s Human Resources Department if I am ever convicted of a felony, while employed at ENHSA. *Applicants are not obligated to disclose a sealed record.

I understand that, if employed, my employment is for no fixed term. My acceptance of an offer of employment does not create a contractual obligation upon this employer to continue to employ me in the future.

As a condition of employment, I hereby voluntarily give my consent to this company and its designated agents to do urinalysis and/or blood testing for alcohol and/or controlled substances. Such testing may occur as a precondition to my being employed, or at any time during my employment with this company when there is reasonable cause to believe that violation of the Drugs and Alcohol Policy (ENHSA Personnel Policy 8.25) has occurred. I understand that refusal to submit to such testing will result in my termination. For those positions which require a pre-employment drug screen and/or physical examination, I understand and acknowledge that any offer of employment to me is contingent upon their successful completion.

I further understand that ENHSA may run an internal search of the Department of Motor Vehicle Database at the pre-employment stage, and/or at any time during my employment should I be hired. By providing the following information and signing below, I authorize ENHSA to run such search as required.

Name

Today's Date*

Phone

This field is for validation purposes and should be left unchanged.