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#soliloquy-container-295{opacity:1}#soliloquy-container-295 li > .soliloquy-caption{display:none}#soliloquy-container-295 li:first-child > .soliloquy-caption{display:block} Connie's story

Central Iowa Community Integration picnic

Visitors from Optimae's Recovery & Resource Center group poses for a photo at an outdoor shopping mall

You are here: Home / Employment / Application for Employment

Application for Employment

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HR USE ONLY

Location: ____________________________________

Date Hired: _________________________________
We consider qualified applicants for all positions without regard to race, color, religion, gender, gender identities, national origin, age, veteran status, disability, marital status, or any other protected status.
PERSONAL INFORMATION
Region where the job to which you are applying is located:*
- Cedar Valley (Cedar Rapids, Dubuque, Waterloo)
- Central (Adel, Ames, Des Moines metro, Iowa Falls, Knoxville, Marshalltown, Newton, Pella, Winterset)
- Corporate Office
- Great River (Burlington, Fort Madison, Keokuk, Mount Pleasant)
- Mississippi Bend (Muscatine)
- Old Capitol (Iowa City, Marengo, Washington)
- Southern Prairie (Bloomfield, Centerville, Chariton, Fairfield, Keosauqua, Lamoni, Osceola, Ottumwa)
City/region where the job to which you are applying is located:
Name*
First Last
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
Are you 18 years of age or older?*
- Yes
- No
Are you prevented from becoming lawfully employed because of visa or immigration status?*
- Yes
- No
Do you have a criminal record of founded child or dependent adult abuse or have you ever been convicted of a crime in this state or any other state?
- Yes
- No
If your answer was "Yes", please explain:
Due to the nature of our business, we are required to complete background checks prior to hire for most positions. A prior conviction will not necessarily bar you from employment; however, the type of conviction and when it occurred will be considered.
Are you able to perform the essential functions of the position for which you are applying (with or without accommodations)?
- Yes
- No
If "No", what accommodation to this condition would make it possible for you to perform the essential functions of this position?

COMPANY EXPERIENCE
Have you worked for this company before?*
- Yes
- No
From and To Dates
What location?
Position
Reason for leaving
GENERAL
Are you currently employed?*
If not, when was your last day of employment?
Position applying for*
Type*
- Full Time
- Part Time
- Temporary
- Seasonal
How did you hear about this position? (If from a current employee, list name.)*
Rate of pay expected*

EDUCATIONAL BACKGROUND
College - Name
City, State
Did you graduate?
Course or Major
Technical School - Name
City, State
Did you graduate?
Course or Major
High School - Name
City, State
Did you graduate?
Course or Major
Other - Name
City, State
Did you graduate?
Course or Major

LIST ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH MOST RECENT
Upload Resume
Uploaded documents must be Word or PDF files
Accepted file types: pdf, docx.
1. Company Name
Phone
Address
Street Address City State ZIP Code
Dates Worked: From - To
Positions Held
Duties - Responsibilities
Type of Business
Supervisor's Name
Reason for Leaving
Work Hours
Starting Wage
Starting Wage Per
- Hour
- Year
Amount Received (Bonus/Incentives)
2. Company Name
Phone
Address
Street Address City State ZIP Code
Dates Worked: From - To
Positions Held
Duties - Responsibilities
Type of Business
Supervisor's Name
Reason for Leaving
Work Hours
Starting Wage
Starting Wage Per
- Hour
- Year
Amount Received (Bonus/Incentives)
3. Company Name
Phone
Address
Street Address City State ZIP Code
Dates Worked: From - To
Positions Held
Duties - Responsibilities
Type of Business
Supervisor's Name
Reason for Leaving
Work Hours
Starting Wage
Starting Wage Per
- Hour
- Year
Amount Received (Bonus/Incentives)
4. Company Name
Phone
Address
Street Address City State ZIP Code
Dates Worked: From - To
Positions Held
Duties - Responsibilities
Type of Business
Supervisor's Name
Reason for Leaving
Work Hours
Starting Wage
Starting Wage Per
- Hour
- Year
Amount Received (Bonus/Incentives)
Do you hold a professional licensure, credential or certification?*
- Yes
- No

RN License Number
Expiration Date
LPN License Number
Expiration Date
Therapist Type
License Number
Expiration Date
CNA Certification Number
Expiration Date
ARNP License Number
Expiration Date
Other position (please be specific)
License Number
Expiration Date
If applicable, please list state(s) licensed to practice:

REFERENCES
1. Name*
Relationship & Title*
Years Known*
State*
Company*
Work Address*
Home Phone*
Work Phone*
2. Name*
Relationship & Title*
Years Known*
State*
Company*
Work Address*
Home Phone*
Work Phone*

The position you are applying for may require transporting customers. Therefore, we must consider your driving record for employment.
Do you currently have a valid driver’s license?*
Have you been denied a license, permit or privilege to operate a motor vehicle within the last 3 years?
If "Yes," why?
Has any license, permit or privilege been suspended or revoked within the last 3 years?
If "Yes," why?
Have you been in an auto accident in which you were at fault within the last 3 years?
If "Yes," why?
Have you ever driven in snow and ice situations?*
Have you, within the last three years, been required to have SR22 insurance?

CERTIFICATE AND RELEASE OF APPLICANT

** READ CAREFULLY BEFORE SIGNING **

I certify that the information in this application (and accompanying resume or information) is true. I also agree and understand that misrepresentation or false or omitted facts may disqualify me from further consideration for employment and may be considered justification for my termination if discovered at a later date.

I authorize investigations of the statements contained herein, and references listed above to give you any and all information such persons, schools, and employers or organizations may have, and release all parties from all liability for any damage that may result from furnishing this information to you. I authorize you to request and receive any and all information from my entire work and personal history.

I understand that, if hired, my employment is for no definite period and may be terminated at any time, with or without cause, at the discretion of either the company or myself. I understand that I will remain an at-will employee and can be terminated at any time, with or without notice, absent a written contract signed by the Chief Executive Officer of the company and myself. If I am employed, it is also understood that Optimae, at its sole option and without prior notice, can change wages, benefits, rules, regulations and the conditions of my employment at any time.
I acknowledge that I may be offered employment subject to a medical examination and/or questionnaire, and that such examination and/or questionnaire could nullify my ultimate employment by this employer. I agree to submit to any such medical examination and/or questionnaire.
Signature*
Date Signed*
Name
This field is for validation purposes and should be left unchanged.