Create Account
Personal Information
Full Name
Address
Home Telephone
Busines Telephone
Cell Telephone
Social Security Number
Date of Birth
Height
Weight
Driver License Number and State
Have you had three or more moving violations within the last three years
Yes
No
Have you ever been employed here before
Yes
No
Are you employed now?
Yes
No
Date Available to work
Are you on a lay-off subject to recall
Yes
No
Enter your account information
Date of Application
Position(s) Applied For
Minimum Starting Salary Expected
I am available to work the following shift(s)
7-3
3-11
11-7
Referral Source
Advertisement
Friend
Relative
Employment Agency
Other
Voluntary Health Questions
Current status of your health
List any physical, mental disorders or serious illnesses in the past five year
Any handicaps? Please Explain
Have you ever been compelled to discontinue study or work for a substantial period because of illness, physical injury or nervous disturbance?
Yes
No
If yes, give details and dates
Give date of last complete physical.
If over one year are you willing to obtain a physical exam at your own expense?
Yes
No
Are you under treatment for any chronic condition at this time?
Yes
No
In case of emergency notify:
Education
High School Name and location
Attended from
To
Did you graduate?
Yes
No
College Name and location
Attended from
To
Major
Degree Awarded
Minor
Total Semester Hours
Graduate Work
Yes
No
University
Dates
Did you graduate?
Yes
No
Subjects taken
Other training:
Hobbies and spare time interests:
Would you be willing to attend training sessions on your own time?
Yes
No
Military Services
Veteran
Yes
No
Branch of Service
Dates Served
Highest rank
Present Reserve Status
Background Information
Have you ever been convicted of a felony? (conviction will not necessarily disqualify applicant from employment)
Yes
No
If yes explain:
Have you engaged in sexual abuse/harassment in a juvenile facility or any other institution?
Yes
No
Have you ever been convicted in engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?
Yes
No
Have you ever been civilly or administratively adjudicated to have engaged in the activity described in the previous question?
Yes
No
Please know that if you have employment experience at a jail, prison, juvenile or other institution, it is our policy to call to ask about substantiated allegations of abuse or harassment.
Employment Experiences
Start with your present or last job. Include military service assignments and volunteer activities. You may exclude organization names which indicate race, color, religion, gender, national origin, handicap or other protected status.
(1)EMPLOYER
TELEPHONE NUMBER
Dates Employed from
To
ADDRESS
JOB TITLE
Supervisor
Reasons for Leaving
Hourly Rate/Salary Starting
Final
Work Performed
(2)EMPLOYER
TELEPHONE NUMBER
Dates Employed from
To
ADDRESS
JOB TITLE
Supervisor
Reasons for Leaving
Hourly Rate/Salary Starting
Final
Work Performed
(3)EMPLOYER
TELEPHONE NUMBER
Dates Employed from
To
ADDRESS
JOB TITLE
Supervisor
Reasons for Leaving
Hourly Rate/Salary Starting
Final
Work Performed
(4)EMPLOYER
TELEPHONE NUMBER
Dates Employed from
To
ADDRESS
JOB TITLE
Supervisor
Reasons for Leaving
Hourly Rate/Salary Starting
Final
Work Performed
VOLUNTARY SURVEY
Government agencies at times require reports on the sex, ethnicity, veteran handicapped and other protected status of applicants. This data is only for analysis and possible affirmative action. SUBMISSION OF INFORMATION IS VOLUNTARY.
Gender
Male
Female
Race
WHITE
BLACKS
HISPANIC
AMERICAN INDIAN/ALASKAN NATIVE
ASIAN/PACIFIC ISLANDERS
SELECT IF ANY OF THE FOLLOWING ARE APPLICABLE:
VIETNAM VETERAN
DISABLED VETERAN
HANDICAPPED
Required REFERENCES
GIVE THE NAME AND TELEPHONE NUMBER OF AT LEAST FOUR REFERENCES WHO ARE NOT RELATED TO YOU AND HAVE DIRECT KNOWLEDGE OF YOUR WORK CAPABILITIES: (PLEASE INCLUDE LETTER OF RECOMMENDATION WITH THIS APPLICATION, IF AVAILABLE
REFERENCES MAY BE FAXED OR EMAILED (318-222-0385)OR-EMAIL therutherfordhouse@gmail.com
NAME
POSITION
PHONE
RELATIONSHIP
IN YOUR OWN WORDS, EXPLAIN WHY YOU FEEL QUALIFIED TO WORK FOR OUR AGENCY, WHAT YOU HOPE TO ACCOMPLISH IN THIS WORK, AND YOUR FEELINGS CONCERNING YOUR WILLINGNESS TO PERFORM BEYOND WHAT MIGHT BE CALLED ADUTY@.
I CERTIFY THAT THE ANSWERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS, INCLUDING MY DRIVING RECORD, CONTAINED IN THIS APPLICATION FOR EMPLOYMENT AS MAY BE NECESSARY IN ARRIVING AT AN EMPLOYMENT DECISION. I ALSO REALIZE THAT, IF HIRED, I WILL BE REQUIRED TO SUBMIT FINGERPRINTS TO THE STATE FOR A CRIMINAL CHECK.
THIS APPLICATION IS ONLY ACTIVE FOR 45 DAYS.
THE APPLICANT UNDERSTANDS THAT NEITHER THIS DOCUMENT NOR ANY OFFER OF EMPLOYMENT FROM THE EMPLOYER CONSTITUTE AN EMPLOYMENT CONTRACT UNLESS A SPECIFIC DOCUMENT TO THAT EFFECT IS EXECUTED BY THE EXECUTIVE DIRECTOR OF RUTHERFORD HOUSE.
IF YOU ARE PRESENTLY HANDICAPPED OR BECOME HANDICAPPED WHILE EMPLOYED AT RUTHERFORD HOUSE, REASONABLE ACCOMMODATIONS WILL BE MADE FOR YOU PROVIDING YOUR LIMITATION DOES NOT POSE A THREAT TO YOUR SAFETY OR THE SAFETY OF OUR STUDENTS.
IN THE EVENT OF EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION GIVEN IN MY APPLICATION OR INTERVIEW MAY RESULT IN DISCHARGE. I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF RUTHERFORD HOUSE AND MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE AT ANY TIME. I UNDERSTAND THAT NO ONE OTHER THAN THE EXECUTIVE DIRECTOR OF RUTHERFORD HOUSE HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.
SINCE RUTHERFORD HOUSE IS A SMOKE FREE FACILITY, I AGREE NOT TO SMOKE DURING WORK HOURS OR ON RUTHERFORD HOUSE PROPERTY.
Signature of Applicant
Date: