Name:

First Middle, Last Names

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone:

(###)

###

####

Cell Phone:

(###)

###

####

Work Phone:

(###)

###

####

May we contact you at work?

Yes

Email:

Date of application:

YYYY

Date available:

YYYY

Position applying for:

Have you applied for a position with ICS before?

Yes

If yes, when?

Have you been employed by ICS before?

Yes

If yes, when and in what position?

How were you referred to ICS:

How did you find out about this employment opportunity?

If "other", please note where you learned about this position:

Additional information

Where was the ad, name of the employee, or more info if other?

Personal Data

Have you ever been convicted of a crime or do you currently have criminal charges pending?

Yes

If yes, please provide additional detail

A criminal conviction is not an automatic bar to employment

Salary expected:

Are you at least 18 years of age?

Yes

Are you legally authorized to work in the U.S.?

Yes

Education

What is your highest level of education?

Provide additional details:

List names and addresses of high school, college, university, or other education attended AND provide the diploma, degree or course of study.

Professional Data

Special skills:

i.e. computer skills, languages, etc.

Have you ever been dismissed or forced to resign from employment?

Yes

If yes, please explain:

Does any member of your family work here now?

Yes

If yes, please list name, department and your relationship:

Provide two professional references:

Name, relationship, number of years known, phone and email address

Employment History

Name and position of present or most recent employment details:

Dates of employment:

Is/was this position full or part-time?

Full-time

Part-time

Briefly describe your duties:

Name of your immediate supervisor and contact information:

Provide employer's address and supervisor's email and phone number

Starting Salary:

Final Salary:

Reason for considering change or leaving?

If currently employed, may we contact your present employer?

Yes

Please provide any additional employment history:

Name of employer, your title, dates employed, full-time or part-time, your immediate supervisor, and their phone or email, employer address, starting and final salary, a brief description of duties, and reason for leaving.

Acknowledgement

I hereby affirm that the information contained in this application (and resume’ if any) is accurate and complete and I understand that any false or misleading information or omissions will disqualify me from employment consideration or result in termination of employment, regardless of when discovered. I hereby authorize Integrated Community Solutions, Inc. to investigate all statements contained in this application related to my background and qualifications; contact my former employers and other listed references or any other persons who can provide information relative to my employment consideration; contact any person or entities regarding my employment application and make any other inquiries that are deemed relevant in arriving at a decision regarding my application for employment. I understand that any investigation conducted may include a request for employment and educational history, credit reports, consumer reports, investigative consumer reports, driving records and criminal history. I hereby release from any and all liability all representatives of Integrated Community Solutions, Inc. for their acts performed in connection with evaluating and investigating my application, credentials and qualifications. I understand that I have the right to make a written request within a reasonable period of time for complete disclosure of the nature and scope of any investigation. I consent to any contacted person to provide information about me and I agree not to sue any such person for information provided about me.

I UNDERSTAND AND ACKNOWLEDGE THAT IF I AM EMPLOYED BY INTEGRATED COMMUNITY SOLUTIONS, MY EMPLOYMENT IS NOT BINDING ON EITHER PARTY FOR ANY SPECIFIED PERIOD OF TIME. I UNDERSTAND THAT IF I AM EMPLOYED, I WILL BE AN EMPLOYEE AT WILL AND MY EMPLOYMENT CAN BE TERMINATED BY EITHER PARTY WITH OR WITHOUT NOTICE AT ANY TIME, FOR ANY REASON OR NO REASON.

By typing my full name, I am affirming I have read, understand, and by my signature, consent to these statements.

Today's Date

YYYY

Other Names Used

If Applicable (maiden name, alias, nickname, etc.)

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