Employment Application Form

UDMO Job Application

Step 1 of 2

Applicant Data

Application Date

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Position Applying For *

Position Location *

Date Available for Employment

1. If you are under 18 years of age, can you provide proof of your eligibility to work?

2. Are you legally eligible for employment in the United States (verification will be required)?

3. Do you have any relative who are employed by UDMO or serve on the Board of Directors or Head Start Policy Council of UDMO?

4. Have you ever been employed with UDMO before?

5 a. Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime in this state or any other state?

5 b. Have you ever been convicted of a felony?

5 c. For Applicants for Head Start and Early Head Start positions ONLY, we are required to ask a a condition of receiving federal funding per 45 CFR 1301.31(b)(2)(i) whether you have any pending or prior criminal arrests and criminal charges related to child sexual abuse.

Do you have any pending or prior criminal arrest and criminal charges related to child sexual abuse?

Education

High School

Name of High School

City/State

College #1

Name of College

City/State

Major

Degree Earned

College #2

Name of College

City/State

Major

Degree Earned

College #3

Name of College

City/State

Major

Degree Earned

Training, Skills & Qualifications

Please list any other trainings, skills or qualifications you may have that would benefit Upper Des Moines Opportunity with your employment.

Do you have a valid driver's license?

Can you travel if/when job requires it?

Reference #1

May not be relatives or employees of the Agency.

Name

First

Last

Phone

Years known

Reference #2

May not be relatives or employees of the Agency.

Name

First

Last

Phone

Years known

Reference #3

May not be relatives or employees of the Agency.

Name

First

Last

Phone

Years known

Employment History

List present or most recent first.

Name of Current Employer

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Position

Date Began

Date Ended

Hourly Rate/Salary

Supervisor

Reason for Leaving

Duties & Responsibilities

Name of Employer #2

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Position

Date Began

Date Ended

Hourly Rate/Salary

Supervisor

Reason for Leaving

Duties & Responsibilities

Name of Employer #3

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Employer #4

Address

Address Line 1

Address Line 2

City

State

Zip Code

Current Employer

Are you currently employed?

May we contact your present employer?

If yes, name of supervisor.

What is your expected Salary for this position?

File Upload

Click or drag files to this area to upload. You can upload up to 4 files.

Please attach your cover letter and/or resume here.

Terms

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Upper Des Moines opportunity, Inc. permission to contact previous employers (unless otherwise indicated), schools, references and others, and hereby release Upper Des Moines Opportunity, Inc. from any liability now or in the future as a result of such contact. I also grant permission to Upper Des Moines Opportunity, Inc. to provide copies of my application materials to employees other than the designated search committee for purposes of determining my suitability for a position. I also understand that I may be required to take a physical exam and that continued employment may be based on the successful passing of job-related physical examinations. I understand that I am to abide by all rules, regulations, and policies of Upper Des Moines Opportunity, Inc. I understand that my employment and compensation may be terminated with or without cause, and with or without notice, at any time, at the option of Upper Des Moines Opportunity, Inc. I further understand that no one other than the Executive Director of Upper Des Moines Opportunity, Inc. has any authority to enter into any agreement for employment or make any agreement to the foregoing.

Signature *

If you chose to complete this section.... PLEASE COMPLETE IN FULL

Date

Position Applied For

Sex

Date of Birth

ETHNIC GROUP: Please select one of the descriptions below corresponding to the ethnic group with which you most identify.

Checkboxes

American Indian or Alaskan Native - A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Island, Thailand, and Vietnam.
Black or African American - A person having origins in any of the Black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "black or African American"
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanic or Latino (All races) - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Hispanic or Latino (White race only) - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of the White race.
Hispanic or Latino (all other races) - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of any race other than White.
Race missing or unknown - Applies to Applicants only where a resume or application that is screened is received without any racial or ethnic indentification and no further contact is made with the applicant.

Applicant Data

Education

High School

College #1

College #2

College #3

Training, Skills & Qualifications

Reference #1

Reference #2

Reference #3

Employment History

Current Employer

Terms

Voluntary Self-Identification (Confidential-for statistical user only)

If you chose to complete this section.... PLEASE COMPLETE IN FULL

ETHNIC GROUP: Please select one of the descriptions below corresponding to the ethnic group with which you most identify.