Impact Job Application Form | Impact Institute

Impact Institute Job Application Form

Equal access to programs, services and employment opportunities is available to all persons without regard to race, color, religion, sex (including pregnancy), national origin, ancestry, age, disability, veteran status, genetic information, or any other basis protected by federal, state, and/or local laws. In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations making a change to the application process providing written materials in an alternate format such as braille, large print, or audio recording: using a sign language interpreter: using specialized equipment: or modifying testing conditions.

Personal Information: First Name:

Last Name

Street Address

City

State

Zip Code

Email Address

Phone Number

Position Applied For

Referral Source

Contact Information: If necessary, best time to call is?

At what Phone Number

May we contact you at work?

Best time to contact at work?

Work Phone

Employment Eligibility: Date Available to Work:

Have you submitted an application here before?

If yes, date and position?

Have you ever been employed here before?

If yes, what dates?

Is this application a request for reemployment following an extended military leave of absence from this company?

Are you lawfully authorized to work in the United States?

Have you entered into an agreement with any former employer or other party (such as noncompetion agreement) that might, in any way restrict your ability to work for our company?

Driver's license number and state required if driving may be required in the job for which you ar applying:

Employment Preferences: What is your desired salary range or rate of pay?

Per Hour?

Type of Employment desired:

If they have been explained to you, will you be able to meet the attendance requirements of this position?

Will you work overtme if it is required?

If no, please explain...

Reasonable Accomodation: Are you able to perform the “essential functions” of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary.

Criminal Background: Have you ever been convicted of a crime that has not been expunged by the court? NOTE: Answering "yes" to this question does not constitute an automatic bar to employment. Factors such as date of offense, seriousness, and nature of the violation, rehabilitaton, and position applied for will be taken into account.

Have you ever been bonded?

Employment History: Starting with your most recent employer, provide the following information:

Phone Number

Dates Employed

Starting Job Title

Final Job Title

Immediate supervisor and title (for most recent position held):

May we contact for a reference?

Email Address:

Phone Number

Why did you leave?

Summarize the type of work performed and job responsibilities

What did you like most about yor position?

What did you like least about your position?

Compensation (Starting)

Compensation (Starting, Hourly)

Compensation (Final)

Compensation (Final, Hourly)

Explain any gaps in your employment, other than those due to personal illness, injury, or disability:

Skills and Qualifications: Summarize any special training, skills, languages, licenses, bonding, certifications, and/or certificates that may assist you in performing the position for which you are applying.

Computer skills (include software titles and level of experience, such as basic, intermediate, or advanced.

Software Names:

Skill Levels

Education Background: School Name

City and State

Number of Years Completed

Level Completed

GPA / Class Rank

Major/Minor/Certificate

School Name

City and State

Number of Years Completed

Level Completed

GPA / Class Rank

Major/Minor/Certificate

School Name

City and State

Number of Years Completed

Level Completed

GPA / Class Rank

Major/Minor/Certificate

References: Name:

Title:

Relationship to You:

Number of Years Known:

Phone Number

Email Address:

Name:

Title:

Relationship to You:

Number of Years Known:

Phone Number

Email Address:

Name:

Title:

Relationship to You:

Number of Years Known:

Phone Number

Email Address:

In answering these questions, please exclude any infomation that would reveal race, color, religion, sex (including pregnancy), national origin, ancestry, age, disability, veteran status, genetic information, or other similarly protected status. To what job related organizations (professional, trade, etc.) do you belong?

List any relevant volunteer work:

List special accomplishments, publications, awards, etc:

Is there any other job related information you want us to know about you?

Your Signature

Select a date

Pleae Read the Application Terms and Conditions Below, then Check the Box to Agree. Thank You.

Thank You for Submitting! We will be in touch with you shortly.

Application Terms & Conditions

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete, and correct.
I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and al rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer’s affiliate or third party to be used solely to perform the services requested by the employer.
The Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her race, color, religion, sex (including pregnancy), national origin, ancestry, age, disability, veteran status, genetic information, or any other protected status under applicable federal, state or local law.
NOTE: This Company complies with Indiana law prohibiting smoking in enclosed areas within places of employment.