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Employment Application

Background Information

First Name:
Middle Name:
Last Name:
Email:
Social Security No (last 4 digits only):

List your addresses of residency for the past 3 years.

Current Address
Street:   City:
State:   Zip Code:
Phone Number: (###-###-####)   How long at this address?

Previous Address 1
Street:   City:
State:   How long at this address?
Zip:    

Previous Address 2
Street:   City:
State:   How long at this address?
Zip:    

Previous Address 3
Street:   City:
State:   How long at this address?
Zip:    

Are you legally eligible for employment in the United States?:
YES    NO

Employment Desired

Position: Purchasing Analyst, Shared Services - Illinois - Chicagoland
Start Date (mm/dd/yyyy)
Desired Salary
Are you employed now?
YES    NO
If so, may we inquire of your present employer?
YES    NO
Have you ever applied to this Company or any VCNA Prairie, Inc. affiliated Company before?
YES    NO
If yes, where?
When?
Referred by
Employee Referral Name

Driver Experience and Qualifications

License State 1
License State:   License Number:
License Class:   License Expiration:
mm/dd/yyyy
License State 2
License State:   License Number:
License Class:   License Expiration:
mm/dd/yyyy
License State 3
License State:   License Number:
License Class:   License Expiration:
mm/dd/yyyy
A.) Have you ever been denied a license, permit or privilege to operate a motor vehicle?
YES    NO
B.) Has any license, permit or privilege ever been suspended, revoked or canceled?
YES    NO
C.) Have you ever been convicted of driving under the influence of alcohol or drugs or any related offense?
YES    NO
D.) Have you ever had any non-DUI traffic convictions in the past 3 years?
YES    NO
E.) Have you ever been involved in any Motor Vehicle accidents in the past 3 years?
YES    NO

If the answer to either A, B, C, D or E is YES, please set forth in detail the acts, circumstances, and dates of such denial, revocation, suspension or conviction:

Education

High School
School Name and Location
No. of Years Attended
Subjects Studied
Did You Graduate?
YES    NO

College
School Name and Location
No. of Years Attended
College Major
Did You Graduate?
YES    NO
Graduate School
School Name and Location
No. of Years Attended
Major
Did You Graduate?
YES    NO
Trade, Business or Correspondence School
School Name and Location
No. of Years Attended
Trade School Subjects
Did You Graduate?
YES    NO

Skills

Typing Skills
YES    NO
Typing WPM
Word Processing Skills
YES    NO
Switchboard Skills
YES    NO
Microsoft Word
YES    NO
Microsoft Excel
YES    NO
Software Programs
Other Skills
Please include any other information you think would be helpful to us in considering you for employment such as additional training, special courses, work experience, activities, accomplishments, etc.
(Exclude all information which indicates your membership in any of the protected groups listed in the disclaimer at the top of this application.)

Work Experience

List ALL work experience in the past 10 years, beginning with the most recent.

Most Recent Employer
Employer Name: Type of Business:
From:
mm/dd/yyyy
To:
mm/dd/yyyy
Address: Telephone:
City: State:
Zip:
Your Position: Immediate Supervisor:
Supervisor Position: Person we may contact to
verify employment:
Current/Last Salary:    
Work Performed (Include whether you operated a commercial motor vehicle and the type of vehicle(s) operated)

Reason for Leaving

Employer 2
Employer Name: Type of Business:
From:
mm/dd/yyyy
To:
mm/dd/yyyy
Address: Telephone:
City: State:
Zip:
Your Position: Immediate Supervisor:
Supervisor Position: Person we may contact to verify employment:
Current/Last Salary:    
Work Performed (Include whether you operated a commercial motor vehicle and the type of vehicle(s) operated)

Reason for Leaving

Employer 3
Employer Name: Type of Business:
From:
mm/dd/yyyy
To:
mm/dd/yyyy
Address: Telephone:
City: State:
Zip:
Your Position: Immediate Supervisor:
Supervisor Position: Person we may contact to verify employment:
Current/Last Salary:    
Work Performed (Include whether you operated a commercial motor vehicle and the type of vehicle(s) operated)

Reason for Leaving

Employer 4
Employer Name: Type of Business:
From:
mm/dd/yyyy
To:
mm/dd/yyyy
Address: Telephone:
City: State:
Zip:
Your Position: Immediate Supervisor:
Supervisor Position: Person we may contact to verify employment:
Current/Last Salary:    
Work Performed (Include whether you operated a commercial motor vehicle and the type of vehicle(s) operated)

Reason for Leaving

Employer 5
Employer Name: Type of Business:
From:
mm/dd/yyyy
To:
mm/dd/yyyy
Address: Telephone:
City: State:
Zip:
Your Position: Immediate Supervisor:
Supervisor Position: Person we may contact to verify employment:
Current/Last Salary:    
Work Performed (Include whether you operated a commercial motor vehicle and the type of vehicle(s) operated)

Reason for Leaving

Employer 6
Employer Name: Type of Business:
From:
mm/dd/yyyy
To:
mm/dd/yyyy
Address: Telephone:
City: State:
Zip:
Your Position: Immediate Supervisor:
Supervisor Position: Person we may contact to verify employment:
Current/Last Salary:    
Work Performed (Include whether you operated a commercial motor vehicle and the type of vehicle(s) operated)

Reason for Leaving

Employer 7
Employer Name: Type of Business:
From:
mm/dd/yyyy
To:
mm/dd/yyyy
Address: Telephone:
City: State:
Zip:
Your Position: Immediate Supervisor:
Supervisor Position: Person we may contact to verify employment:
Current/Last Salary:    
Work Performed (Include whether you operated a commercial motor vehicle and the type of vehicle(s) operated)

Reason for Leaving

Resume Upload
If you have a resume file, upload it here. Only ".doc", ".docx", ".pdf" and ".rtf" files are accepted.

Select Resume File to Upload:
(Optional) 


Voluntary Survey

COMPLETING THE FOLLOWING FIELDS IS VOLUNTARY AND IS NOT A REQUIREMENT FOR EMPLOYMENT:
Race:
Sex:
How you were referred to VCNA Prairie, Inc. :
Type of position you're applying for:
Are you a veteran of the U.S. Armed Forces?
YES    NO
If yes, describe tour or action:
I decline my participation in this voluntary survey:
YES    NO

Submit

I understand in filling out this application that VCNA Prairie, Inc. is in no way obligated to offer me employment.  I certify that the facts set forth in my application for employment are true, correct and complete.  I agree that any misrepresentation or false statement of this application shall be considered grounds for rejecting this application, rescinding a tentative job offer or immediate discharge if discovered after hire.  I authorize VCNA Prairie, Inc. to investigate any of the information contained on this application, including the examination of past employment records, references and other facts stated on the application.  I waive any rights which I may have to receive written notice from any former employer listed on this application regarding the release to VCNA Prairie, Inc. of any information concerning any disciplinary action taken against me by said former employers.  I understand that I will be required to successfully complete a post-offer medical examination as a condition of employment, including drug and alcohol testing, and I agree to take such examination.

I agree, if hired, to submit, at any reasonable time during my employment, and without notice, to a drug and/or alcohol-screening test. I understand that refusal to take a requested drug and/or alcohol screening test may result in discharge. I further understand that, if employed, a positive test result may also result in immediate discharge.

I agree, if hired, to wear or use protective clothing or devices as required and to fully comply with all relevant safety rules. If hired, I agree to conform with all rules and regulations.

I also recognize and accept the right of VCNA Prairie, Inc. to unilaterally modify, amend, or eliminate any policies, handbooks, rules or procedures in its sole discretion at any time.

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

[ You must agree to terms in order to submit application ]