Application for Employment Step 1 of 8 12% 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 INFORMATIONRegion 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 OfficeGreat 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell PhoneAre 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 EXPERIENCEHave you worked for this company before?* Yes No From and To DatesWhat location?PositionReason for leavingGENERALAre 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 BACKGROUNDCollege - NameCity, StateDid you graduate?Course or MajorTechnical School - NameCity, StateDid you graduate?Course or MajorHigh School - NameCity, StateDid you graduate?Course or MajorOther - NameCity, StateDid you graduate?Course or Major LIST ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH MOST RECENTUpload ResumeUploaded documents must be Word or PDF filesAccepted file types: pdf, docx.1. Company NamePhoneAddress Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Dates Worked: From - ToPositions HeldDuties - ResponsibilitiesType of BusinessSupervisor's NameReason for LeavingWork HoursStarting WageStarting Wage Per Hour Year Amount Received (Bonus/Incentives)2. Company NamePhoneAddress Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Dates Worked: From - ToPositions HeldDuties - ResponsibilitiesType of BusinessSupervisor's NameReason for LeavingWork HoursStarting WageStarting Wage Per Hour Year Amount Received (Bonus/Incentives)3. Company NamePhoneAddress Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Dates Worked: From - ToPositions HeldDuties - ResponsibilitiesType of BusinessSupervisor's NameReason for LeavingWork HoursStarting WageStarting Wage Per Hour Year Amount Received (Bonus/Incentives)4. Company NamePhoneAddress Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Dates Worked: From - ToPositions HeldDuties - ResponsibilitiesType of BusinessSupervisor's NameReason for LeavingWork HoursStarting WageStarting Wage Per Hour Year Amount Received (Bonus/Incentives)Do you hold a professional licensure, credential or certification?*YesNo RN License NumberExpiration Date LPN License NumberExpiration Date Therapist TypeLicense NumberExpiration Date CNA Certification NumberExpiration Date ARNP License NumberExpiration Date Other position (please be specific)License NumberExpiration Date If applicable, please list state(s) licensed to practice: REFERENCES1. 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* EmailThis field is for validation purposes and should be left unchanged.