Application for Employment-Receiving Assistant

COMPLETE ALL SECTIONS. WRITE IN “N/A” IF REQUESTED INFORMATION IS NOT APPLICABLE.

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* 1. Applicant Information

Name (First, Middle, Last)

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Position Applying For

ReStore Receiving Assistant

ReStore Driver

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* 3. Are you legally authorized to work in the United States?

Yes

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* 4. Do any members of your immediate family serve on the Habitat for Humanity La Crosse Area Board of Directors?

Note: Immediate family is defined as spouse, parent, child, sibling, father-in-law, mother-in-law, brother-in-law, sister-in-law, grandparent, grandchild, aunt, uncle, niece, nephew, stepparent, stepchild, son-in-law and daughter-in-law.

Yes

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* 5. Are any members of your immediate family currently employed by Habitat for Humanity La Crosse Area?

Note: Immediate family is defined as spouse, parent, child, sibling, father-in-law, mother-in-law, brother-in-law, sister-in-law, grandparent, grandchild, aunt, uncle, niece, nephew, stepparent, stepchild, son-in-law and daughter-in-law.

Yes

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* 6. If question 4 or 5 was answered "YES", give name of family member:

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* 7. Have you ever been employed by Habitat for Humanity La Crosse Area before?

Yes

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* 8. If question 7 was answered "YES", give position(s) held and dates.

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* 9. Are you available for work immediately?

Yes

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* 10. If answered "NO" to question 9, on what date would you be available?

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* 11. What is your work availability? (Select all that apply)

Full time

Part time

Temporary

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* 12. Can you travel if the job requires it?

Yes

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* 13. Do you have dependable transportation?

Yes

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* 14. Do you hold a valid driver’s license?

Yes

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* 15. Do you carry auto insurance coverage?

Yes

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* 16. High School Education

Name of school

Address of school

Number of years completed

Did you receive a diploma

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* 17. Technical School/College Education

Name of High School

Address of High School

Number of years completed

Did you graduate

Describe course of study

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* 18. Graduate/Prof. Education

Name of High School

Address of High School

Number of years completed

Did you graduate

Describe course of study

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* 19. Describe specialized training, skills, apprenticeships:

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* 20. EXPERIENCE: BEGIN WITH CURRENT OR MOST RECENT JOB OR VOLUNTEER EXPERIENCE AND WORK BACK. ACCOUNT FOR PERIODS OF UNEMPLOYMENT EXCEEDING THREE MONTHS ON THE LAST LINE OF EXPERIENCE BLOCKS IN ORDER OF OCCURRENCE.

Name of Employer

Address of Employer

Phone of Employer

Date of Employment (Include start month/year and ending month/year)

Title of Position

Salary or Earnings (Include beginning $ and ending $)

Reason for Leaving

Name of Immediate Supervisor

May we contact this employer? Yes or No

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* 21. For the job or volunteer experience listed above, description of work (describe specific duties, responsibilities and accomplishments in job)

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* 22. EXPERIENCE: BEGIN WITH CURRENT OR MOST RECENT JOB OR VOLUNTEER EXPERIENCE AND WORK BACK. ACCOUNT FOR PERIODS OF UNEMPLOYMENT EXCEEDING THREE MONTHS ON THE LAST LINE OF EXPERIENCE BLOCKS IN ORDER OF OCCURRENCE.

Name of Employer

Address of Employer

Phone of Employer

Date of Employment (Include start month/year and ending month/year)

Title of Position

Salary or Earnings (Include beginning $ and ending $)

Reason for Leaving

Name of Immediate Supervisor

May we contact this employer? Yes or No

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* 23. For the job or volunteer experience listed above, description of work (describe specific duties, responsibilities and accomplishments in job)

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* 24. EXPERIENCE: BEGIN WITH CURRENT OR MOST RECENT JOB OR VOLUNTEER EXPERIENCE AND WORK BACK. ACCOUNT FOR PERIODS OF UNEMPLOYMENT EXCEEDING THREE MONTHS ON THE LAST LINE OF EXPERIENCE BLOCKS IN ORDER OF OCCURRENCE.

Name of Employer

Address of Employer

Phone of Employer

Date of Employment (Include start month/year and ending month/year)

Title of Position

Salary or Earnings (Include beginning $ and ending $)

Reason for Leaving

Name of Immediate Supervisor

May we contact this employer? Yes or No

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* 25. For the job or volunteer experience listed above, description of work (describe specific duties, responsibilities and accomplishments in job)

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* 26. Other Professional References (not former employers or relatives)

Name

Business or Home Address

Phone Number

E-mail

Business/Occupation

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* 27. Other Professional References (not former employers or relatives)

Name

Business or Home Address

Phone Number

E-mail

Business/Occupation

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* 28. Other Professional References (not former employers or relatives)

Name

Business or Home Address

Phone Number

E-mail

Business/Occupation

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* 29. A FALSE, INCOMPLETE, OR DISHONEST ANSWER TO ANY QUESTION ON THIS APPLICATION WILL BE GROUNDS FOR RATING AN APPLICANT INELIGIBLE FOR EMPLOYMENT WITH THIS AGENCY, OR FOR DISMISSAL AFTER EMPLOYMENT. ALL STATEMENTS ON THIS APPLICATION ARE SUBJECT TO INVESTIGATION (EXCEPT WHERE NOTED IN #12 ABOVE). ALL INFORMATION WILL BE CONSIDERED IN DETERMINING AN APPLICANT’S ELIGIBILITY FOR EMPLOYMENT WITH THIS AGENCY. I RELEASE HABITAT FOR HUMANITY LA CROSSE AREA FROM ALL CLAIMS AND LIABILITIES REGARDING REFERENCES GIVEN. I UNDERSTAND ALSO, THAT IF HIRED, I WILL BE REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE ORGANIZATION. I UNDERSTAND THAT MY EMPLOYMENT WOULD BE FOR NO SPECIFIC PERIOD OF TIME AND THAT I MAY BE TERMINATED AT ANY TIME.

Name (Signature)

Date

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* 30. AFFIRMATIVE ACTION SURVEY

Habitat for Humanity La Crosse Area is an equal opportunity employer and strives to comply with all government regulations and affirmative action responsibilities. Applicants are considered for all positions and employees are treated during employment without regard to race, color, sex, national origin, age, marital or veteran status, sexual orientation, or disabling condition.

We are required to collect data requested on this questionnaire for record keeping and to document affirmative action efforts. While your reply will be most helpful to us in carrying out our administrative responsibilities, return of this form is entirely voluntary.

This questionnaire will be detached from your application upon receipt. This information will not be seen or used by people involved in screening or in the interviewing processes for applicants. This data will be kept in a confidential file separate from your job application.

Thank you for your cooperation!

Yes, I chose to participate

No, I chose not to participate

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* 31. Position Applied for

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* 32. Date Applied for the Position

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* 33. How did you first find out about this job opening?

Job Service

Friend/Relative

Walk-in/Inquiry

Internet

From an employee of Habitat

Other (please specify)

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* 34. Gender

Male

Female

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* 35. Age 40 or over

Yes

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* 36. Race

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

Native Hawaiian or other Pacific Islander

More than One Race

Other Race

Unknown

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* 37. Ethnicity

Hispanic or Latino

Not Hispanic/Latino

Unknown

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* 38. Disability or Handicap

Please DO NOT tell us the disability or handicap you have – just whether or not you have a disability or handicap or perceive yourself as having one.

Yes

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* 39. Veteran

Yes

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* 40. Vietnam Era Veteran

Yes

Application for Employment-Receiving Assistant

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* 1. Applicant Information

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* 2. Position Applying For

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* 3. Are you legally authorized to work in the United States?

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* 6. If question 4 or 5 was answered "YES", give name of family member:

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* 7. Have you ever been employed by Habitat for Humanity La Crosse Area before?

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* 8. If question 7 was answered "YES", give position(s) held and dates.

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* 9. Are you available for work immediately?

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* 10. If answered "NO" to question 9, on what date would you be available?

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* 11. What is your work availability? (Select all that apply)

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* 12. Can you travel if the job requires it?

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* 13. Do you have dependable transportation?

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* 14. Do you hold a valid driver’s license?

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* 15. Do you carry auto insurance coverage?

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* 16. High School Education

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* 17. Technical School/College Education

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* 18. Graduate/Prof. Education

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* 19. Describe specialized training, skills, apprenticeships:

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* 20. EXPERIENCE: BEGIN WITH CURRENT OR MOST RECENT JOB OR VOLUNTEER EXPERIENCE AND WORK BACK. ACCOUNT FOR PERIODS OF UNEMPLOYMENT EXCEEDING THREE MONTHS ON THE LAST LINE OF EXPERIENCE BLOCKS IN ORDER OF OCCURRENCE.

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* 21. For the job or volunteer experience listed above, description of work (describe specific duties, responsibilities and accomplishments in job)

Question Title

* 22. EXPERIENCE: BEGIN WITH CURRENT OR MOST RECENT JOB OR VOLUNTEER EXPERIENCE AND WORK BACK. ACCOUNT FOR PERIODS OF UNEMPLOYMENT EXCEEDING THREE MONTHS ON THE LAST LINE OF EXPERIENCE BLOCKS IN ORDER OF OCCURRENCE.

Question Title

* 23. For the job or volunteer experience listed above, description of work (describe specific duties, responsibilities and accomplishments in job)

Question Title

* 24. EXPERIENCE: BEGIN WITH CURRENT OR MOST RECENT JOB OR VOLUNTEER EXPERIENCE AND WORK BACK. ACCOUNT FOR PERIODS OF UNEMPLOYMENT EXCEEDING THREE MONTHS ON THE LAST LINE OF EXPERIENCE BLOCKS IN ORDER OF OCCURRENCE.

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* 25. For the job or volunteer experience listed above, description of work (describe specific duties, responsibilities and accomplishments in job)

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* 26. Other Professional References (not former employers or relatives)

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* 27. Other Professional References (not former employers or relatives)

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* 28. Other Professional References (not former employers or relatives)

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* 31. Position Applied for

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* 32. Date Applied for the Position

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* 33. How did you first find out about this job opening?

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* 34. Gender

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* 35. Age 40 or over

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* 36. Race

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* 37. Ethnicity

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* 38. Disability or HandicapPlease DO NOT tell us the disability or handicap you have – just whether or not you have a disability or handicap or perceive yourself as having one.

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* 39. Veteran

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* 40. Vietnam Era Veteran

* 38. Disability or Handicap

Please DO NOT tell us the disability or handicap you have – just whether or not you have a disability or handicap or perceive yourself as having one.