bsss-employment-application

BIG SKY SENIOR SERVICES

APPLICATION FOR EMPLOYMENT
935 Lake Elmo Dr., Ste. B
Billings, MT 59105
406-259-3111

BIG SKY SENIOR SERVICES IS AN EQUAL OPPORTUNITY EMPLOYER

All applicants are considered for positions applied for without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

BSSS strives to maintain a safe and drug free environment by conducting background checks and drug tests as permitted by law.
Position Applying for: *
Date *

Month Day Year
Date
How did you learn about us?

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PERSONAL INFORMATION
Name *

First Name Middle Name Last Name
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you available to work: *

Full Time Part Time Temporary Seasonal
Date available for work

Month Day Year
Date
Are you over 18 years of age? *

Yes No
Have you filled out an application with us before? *

Yes No
If yes to above, please give date of previous application

Month Day Year
Date
Have you ever been employed by Big Sky Senior Services before? *

Yes No
If yes to above, please give date of previous hiring

Month Day Year
Date
Do any of your friends or relatives work here? *

Yes No
Are you currently employed? *

Yes No
May we contact your present employer? *

Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? (Proof of citizenship will be required upon employment.) *

Yes No
Would you be able to carry and provide proof of required car insurance of $100K/$300K under Liability? *

Yes No
Would you be able to provide a driving record for us? *

Yes No
During the last 10 years, have you been convicted of a crime other than a minor traffic offense? *

Yes No
If yes to above, please explain. (A "yes" answer will not automatically disqualify you from employment. Factors such as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.)
Education: High School
Name of School* Address of School* Years Completed*
Diploma/Degree*
Education: Undergraduate College
Name of School Address of School Years Completed
Diploma/Degree
Education: Graduate/Professional
Name of School Address of School Years Completed
Diploma/Degree
Education: Other
Name of School Address of School Years Completed
Diploma/Degree
EMPLOYMENT HISTORY

Start with your present or most recent job. Include any job-related military services assignments and volunteer activities.
Company nameCompany AddressAddress Person to contact Contact PhonePhone
Start Date

Month Day Year
Date
End Date (leave blank if current employer)

Month Day Year
Date
Starting Salary:blanks Ending Salary: blank
Reason for leaving
Job Description (duties, skills, equipment used)
May we contact this employer?

Yes No
Company nameCompany AddressAddress Person to contact Contact PhonePhone
Start Date

Month Day Year
Date
End Date (leave blank if current employer)

Month Day Year
Date
Starting Salary:$ Ending Salary: $
Reason for leaving
Job Description (duties, skills, equipment used)
May we contact this employer?

Yes No
Company nameCompany AddressAddress Person to contact Contact PhonePhone
Start Date

Month Day Year
Date
End Date (leave blank if current employer)

Month Day Year
Date
Starting Salary:$ Ending Salary: $
Reason for leaving
Job Description (duties, skills, equipment used)
May we contact this employer?

Yes No
Additional comments on previous employment (explanation for gaps in employment, etc.)
ADDITIONAL INFORMATION
Skills and Qualifications: summarize any training, skills, areas of specialization or major interest that may qualify you as being able to perform job-related functions in the position for which you are applying. Include any health care, business, or industrial equipment operated.
United States Military Training. Summarize any job-related training you received in the United States Military.
Professional Licenses and/or Certifications

If licensed, registered, or certified, list below.
TypeState Issued Date Issued #
TypeState Issued Date Issued #
Personal References

Do not include family members
blanks blank
blanks blank
blanks blank
Applicant's Statement

I confirm that all answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this "at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. This application for employment shall be considered active for a period of time not to exceed 180 days. Beyond this time period I may inquire as to whether or not applications are currently being accepted.
Date *

Month Day Year
Date
Signature *

Clear
Note to Applicants: Do not answer the following questions unless you have been informed about the requirements of the job for which you are applying.
Have you reviewed the environmental and ergonomic activities involved in the job or occupation for which you have applied?

Yes No
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied?

Yes No
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