Job Application

Title: Division Assistant

Fields marked with an asterisk (*) must be filled out before submitting.

Name
Position Status Desired:
How did you hear about our organization?

Personal Details

First Name
Middle Initial
Last Name
Current Address
City
State
Zip Code
What telephone number may we contact you at?
Have you ever been employed with Open Options or UCP of Greater Kansas City? Yes
No
If yes, when?
Are you related to any of our current employees? Yes
No
If yes, whom?
Are you related to any person we serve? Yes
No
If yes, whom?
What shifts are you available to work? (Check all that apply) Morning
Afternoon
Evening
Overnight
What days of the week are you available to work? Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Will you work overtime if asked? Yes
No
When are you available to begin work?
Why do you wish to become employed with our organization? What contributions do you feel you can make?

Employment History

If available, please upload your resume, accounting for your employment history for the last 10 years.

Current or Last Employer

Name of Employer
Address
City
State
Zip Code
Type of Business
Phone Number
Start Date
End Date
Starting Salary
Ending Salary
Job Title
Status Full-time
Part-time
Name of Supervisor
Were you fired? Yes
No
If yes, explain the circumstances for leaving.
If we contact this employer, would you expect them to say they would rehire you for the position you last held there? Yes
No
Description of job tasks/responsibilities:
May we contact your current employer? Yes
No

Previous Employer 1

Name of Employer
Address
City
State
Zip Code
Type of Business
Phone Number
Start Date
End Date
Starting Salary
Ending Salary
Job Title
Status Full-time
Part-time
Name of Supervisor
Were you fired? Yes
No
If yes, explain the circumstances for leaving.
If we contact this employer, would you expect them to say they would rehire you for the position you last held there? Yes
No
Description of job tasks/responsibilities

Previous Employer 2

Name of Employer
Address
City
State
Zip Code
Type of Business
Phone Number
Start Date
End Date
Starting Salary
Ending Salary
Job Title
Status Full-time
Part-time
Name of Supervisor
Were you fired? Yes
No
If yes, explain the circumstances for leaving.
If we contact this employer, would you expect them to say they would rehire you for the position you last held there? Yes
No
Description of job tasks/responsibilities

Previous Employer 3

Name of Employer
Address
City
State
Zip Code
Type of Business
Phone Number
Start Date
End Date
Starting Salary
Ending Salary
Job Title
Status Full-time
Part-time
Name of Supervisor
Were you fired? Yes
No
If yes, explain the circumstances for leaving.
If we contact this employer, would you expect them to say they would rehire you for the position you last held there? Yes
No
Description of job tasks/responsibilities
Please provide any additional employment history information here

Education

Highest elementary or high school grade completed
Did you graduate from high school? Yes
No
High School Name and Location
If no, did you complete GED training and receive a certificate? Yes
No

Undergraduate college/university/business or trade school

Name of institution
Dates attended
Major field(s) of study
Degrees conferred

Graduate/professional

Name of Institution
Dates attended
Major field(s) of study
Degrees conferred

Other Experience and Training

Please check any current specialized training and/or certifications you have received that are applicable to working with people with disabilities. Adult CPR
Adult First Aid
Level I Medication Administration Aide
Mandt
CNA
CMT
LPN
RN
Positive Behavior Support
Crisis Intervention
Infection Control
Please list any other specialized trainings, skills or certifications not listed above.
Describe any volunteer work you have performed that is relevant to this field.

Legal Information

Are you legally authorized to work in the United States? (Federal law requires you to produce within 3 business days of hire specific documents establishing your identity and authorization for employment in the US). Yes
No
Drivers license #
State
Expiration Date
In the past 36 months, have you held a drivers license from any other state? Yes
No
If yes, what state and what address appeared on the license?
In the past 36 months, have you been convicted of traffic violations other than parking tickets? Yes
No
If yes, please list month/year and type of offense.
Have you ever been convicted of a felony? Yes
No
If yes, please explain. (Conviction of a crime is not an automatic bar to employment. Multiple Factors will be taken into account when assessing this information).
Professional References (List name, address, and phone number of three persons familiar with your past work. Please do not include personal friends.
Please check the boxes indicating your acceptance. By electronically signing this application for employment, I certify that I have read and understand all parts of the application, and I certify that the information provided by me in this employment application and supplemental employment forms are true, correct, and complete to the best of my knowledge. I certify that this application was completed by me. If employed, any misstatement or omission of fact on this application and supplemental forms may result in termination, regardless of when falsification may be discovered. I understand that additional information may be required in the process of applying for employment.
If accepted for employment, I agree to comply with all the policies, rules, and regulations of this agency. I understand that my employment may be terminated at any time, with or without cause, and with or without notice, at the option of this agency or myself.
Electronic Signature of Applicant