Employment Application

Preparing, empowering and supporting individuals with disabilities.

Employment Application

 

Personal Information

Referral Information

Record of Conviction

(A conviction will not automatically disqualify you for employment. Factors such as date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.)

Driving History

Employment History

List employment starting with your most recent position. Please give an accurate and complete record of all full/part-time employment in the space provided and account for all periods of unemployment. DO NOT place "see resume" or "see previous application." This section must be filled out completely, or this application will not be processed.

Volunteer Experience

List volunteer positions held starting with your most recent position. Please give an accurate and complete record of all volunteer experience. DO NOT place "see resume" or "see previous application." This section must be filled out completely, or this application will not be processed.




Education

Personal References
DO NOT include supervisors already listed above or any relatives




Certification

I hereby authorize the release of any data relevant to my employment with Stone Belt for the purpose of an employment investigation. I authorize a thorough investigation of my past employment, activities, volunteer experience, criminal history, and, when required for a position, my driving record. I agree to cooperate in such investigation, and release from all liability or responsibility all persons and corporations requesting or supplying such information. I understand that Indiana law provides immunity to my previous employers when they disclose information about my employment history, unless the information disclosed was know to be false at the time the disclosure was made.

I agree to submit to any lawful drug, alcohol, or other testing that may be required as a condition of employment or continued employment and understand that refusal to promptly submit and cooperate with such testing prior to or during the course of my employment will result in disqualification from consideration for employment or, if hired, termination.

I full understand that if employed, any misrepresentation or omissions on this application or on any other Stone Belt record will result in dismissal, regardless of the date of discovery. I acknowledge that employment is also subject to a satisfactory review of my references.

This organization takes abuse very seriously. Abuse in any form will not be tolerated.

Neither this application nor any statement made to me during the hiring process or thereafter shall be considered a contract of employment of any kind. Where such a contract is intended, I understand that it will be separately entered into and signed by the Chief Executive Officer of Stone Belt. Absent such a contract, I understand that, if hired, my employment will be terminable-at-will, with or without cause or notice, that I am not being employed for any specific or definite period of time, and that this application is not and is not intended to be a contract, offer, statement, or confirmation of or for continued employment. I understand that any employee handbook or manual does not represent an employment contract if I am hired, and Stone Belt may alter, modify, amend, or terminate any of its policies and benefits, both as to active and retired employees.

Declaration

I declare that I have never committed an act of abuse or fraud in relationship to a dependent person or any crime not disclosed on this application. I declare that I have never knowingly violated applicable rules or laws in any previous employment in residential, health care, or related employment. I understand that a criminal history check will be performed, a drug test administered, and that any ineligibility for coverage by Stone Belt's vehicle insurance policy may result in ineligibility for employment or immediate termination should it occur in the future.