505 College Avenue
Ottawa, IL 61350
(815) 434-1130

www.pvOttawa.org



Employment Application
We are an equal opportunity employer who provides equal access to programs, services and employment to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a Human Resources representative.


Personal Information


* Indicates Mandatory Fields
First Name: * Middle Initial: Last Name:*
Address 1:*
Address 2:
City:* State:*
Zip:*
Home Phone: (xxx-xxx-xxxx)
* Please provide at least one phone number
Cell Phone: (xxx-xxx-xxxx)
E-mail:
Primary position:* Secondary position:
Recruiting Source: If Other:
If referred by an Employee, please provide Employee name:
Have you filed an application with Pleasant View before? If yes, when?
Have you ever been employed at Pleasant View before?*
      If yes, specify where:
      If yes, specify when:
      If yes, specify the reason you left:
Date available to start:* (MM/DD/YYYY)"
Available to work: Full-Time  Part-Time  Shifts  Weekends  Holidays  Temp  Seasonal  Other
      If Other please specify:
Please specify any days or hours not available to work
Will you work overtime if required?


Employment History

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in the comments section below. Please specify ending salary.

1.
Employer's Full Name:* Address:*
City:* State (U.S. only):*
Country:* Zip:*
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Hours per Week:
Job title:*
Type of work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
2.
Employer's Full Name:* Address:*
City:* State (U.S. only):*
Country:* Zip:*
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Hours per Week:
Job title:*
Type of work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
3.
Employer's Full Name:* Address:*
City:* State (U.S. only):*
Country:* Zip:*
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Hours per Week:
Job title:*
Type of work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
4.
Employer's Full Name:* Address:*
City:* State (U.S. only):*
Country:* Zip:*
From Date:* (MM/YYYY) To Date:* (MM/YYYY)
Supervisor Name:* Phone:* (xxx-xxx-xxxx)
Salary per Hours per Week:
Job title:*
Type of work and Duties:*
(Limited to 1000 characters)
Reason for Leaving:*
Please be prepared to explain any gaps in employment.

Education and Training

List last three (3) schools attended, starting with the most recent. B. List number of years completed. C. Indicate degree, diploma or certification earned, if any.

# Institution Name Years Major Diploma Type Diploma Name Graduate
1.
Comments:
2.
Comments:
3.
Comments:
4.
Comments:

Licenses/Certifications Held

List all applicable licenses or certifications that you have and their expiration dates below:

# Type Number State (U.S. Only) Country Expiration Date
(MM/DD/YYYY)
1.
Comments:
2.
Comments:
3.
Comments:
4.
Comments:
General comments (200 characters)

Skills

List any special training that you have completed that may qualify you as being able to perform job-related functions in the position for which you are applying (For example: Clinical experience, Home Health Care, Urgent Care, Senior Care, Pharmacy, Volunteer Services, etc.)

# Skill Type Comments
1.
2.
3.
4.
5.
6.
7.
8.

Employment References

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

# Name Phone
(xxx-xxx-xxxx)
Company Name Title Association with Individual Years Known
1.
2.
3.
4.

Applicant Statement

PLEASE READ AND CHECK "I Accept this Statement” IN THE BOX BELOW.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application or have authorized all information listed on the application.

I hereby authorize the employer to thoroughly investigate my references, work record, education and any other matters related to my suitability for employment and, further, authorize my former employers to disclose any and all of my employment records.

I understand that any information on this application or on any document used to secure employment found to be false, incomplete or misrepresented in any respect will be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I certify I have not been excluded from or sanctioned by any governmental health care benefits program, including but not limited to Medicare, Medicaid, CAMPUS, or the federal retired railway workers benefit program.

I understand and agree that changes in the job duties, responsibilities, work schedule, shifts, working conditions, etc. may occur during my employment.

I authorize to have a criminal background check for employment purposes. I understand my employment offer is conditional pending the results of the background check.

I understand if hired, I must prove that I am legally authorized to work in the United States.

I authorize to have my driving record checked if the position for which I am applying requires driving.

I release the employer and all providers of information from any liability as a result of furnishing and receiving any information related to the hiring process.

I understand, if hired, my employment offer is conditional pending the results of a drug screening.

This application is not, nor is it intended to be, a contract of employment and its terms may be changed at any time. I understand all employees are considered employees at-will. An employee’s employment can be terminated by either the employee or the employer at any time, for any reason, with or without cause or notice, except as otherwise indicated by law. No manager, supervisor, or representative of the employer, other than the President, has any authority to enter into any agreement for employment for any period of time, or to make any agreement contrary to the foregoing.

I understand the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application will remain on file for six (6) months. At the conclusion of that time, if I have not been hired and still wish to be considered for employment, it will be necessary to reapply and complete a new application.
I have read, I understand, and I accept the above statement (please check box to initial)
I agree that the information contained in this application is true and complete to the best of my knowledge. I understand that any falsification, misrepresentation or omission of any facts, as stated or implied, given in my application, interview(s), or other employment forms will be sufficient reason not to hire me and shall be grounds for immediate discharge if I am hired. I further understand that this application is not intended to be a contract of employment.
I have read, I understand, and I accept the above statement (please check box to initial)


Attach Resume If Desired, PDF preferred. If Submit results in errors / incomplete fields, it will be necessary to re-attach the Resume before clicking Submit again.

Please Click Submit ONE Time--Response may take a minute or more. Clicking multiple times may result in your application NOT being processed.