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    THE ALLENDALE ASSOCIATION
    P.O. Box 1088
    Lake Villa, IL 60046-1088
    (847) 356-2351

    POSITION(S) APPLIED FOR:

    DATE OF APPLICATION:

    REFERRAL SOURCE

    NAME OF SOURCE (IF APPLICABLE):

    Name:

    Address:

    Telephone

    Social Security Number:

    If necessary, best time to call you at home is

    May we contact you at work?

    If yes, work number and best time to call

    If you are under 18, can you furnish a work permit?

    Have you ever filed an application here before?

    If yes, give date

    Have you ever been employed here before?

    If yes, give dates

    Are you legally eligible for employment in this country?
    (Proof of identity and legal work authorization will be required upon employment.)

    Date available for work

    Type of employment desired:

    Are you on a lay-off and subject to recall?:

    Would you travel if job requires it?:

    Are there any restrictions on the days or hours that you are available to work?:

    Will you work overtime if required?:

    Will you undergo a post-offer, pre-employment physical?

    "Under Illinois Law, for certain positions we are mandated to do a criminal background check. Passing it will be required for those positions before a final job offer."

    Driver’s License:
    State:

    EMPLOYMENT HISTORY

    List your last four (4) employers, assignments or volunteer activities, starting with most recent, including military experience. Explain any gaps in employment in comments section below.

    EMPLOYER:
    TELEPHONE:
    ADDRESS:
    JOB TITLE
    IMMEDIATE SUPERVISOR AND TITLE
    REASON FOR LEAVING
    MAY WE CONTACT FOR REFERENCE?

    DATES EMPLOYED
    From:
    To:

    HOURLY RATE/SALARY
    Starting
    $:
    Per:

    HOURLY RATE/SALARY
    Final
    $:
    Per:

    Summarize the nature of the work performed and responsibilities.

    EMPLOYER:
    TELEPHONE:
    ADDRESS:
    JOB TITLE
    IMMEDIATE SUPERVISOR AND TITLE
    REASON FOR LEAVING
    MAY WE CONTACT FOR REFERENCE?

    DATES EMPLOYED
    From:
    To:

    HOURLY RATE/SALARY
    Starting
    $:
    Per:

    HOURLY RATE/SALARY
    Final
    $:

    Summarize the nature of the work performed and responsibilities.

    EMPLOYER:
    TELEPHONE:
    ADDRESS:
    JOB TITLE
    IMMEDIATE SUPERVISOR AND TITLE
    REASON FOR LEAVING
    MAY WE CONTACT FOR REFERENCE?

    DATES EMPLOYED
    From:
    To:

    HOURLY RATE/SALARY
    Starting
    $:
    Per:

    HOURLY RATE/SALARY
    Final
    $:
    Per:

    Summarize the nature of the work performed and responsibilities.

    EMPLOYER:
    TELEPHONE:
    ADDRESS:
    JOB TITLE
    IMMEDIATE SUPERVISOR AND TITLE
    REASON FOR LEAVING
    MAY WE CONTACT FOR REFERENCE?

    DATES EMPLOYED
    From:
    To:

    HOURLY RATE/SALARY
    Starting
    $:
    Per:

    HOURLY RATE/SALARY
    Final
    $:
    Per:

    Summarize the nature of the work performed and responsibilities.

    COMMENTS (including explanation of any gaps in employment; attach additional sheets if necessary).

    SKILLS AND QUALIFICATIONS (Summarize special skills and qualifications acquired from employment or other experiences that may qualify for work with our company.).

    EDUCATIONAL BACKGROUND

    A. List last three (3) schools attended, starting with last one. B. List number of years completed. C. major and minor field of study (if applicable). D. Indicate degree or diploma earned, if any.

    A. SCHOOL

    B. NUMBER OF YEARS COMPLETED

    C. MAJOR

    D. DEGREE / DIPLOMA

    E. WERE YOU AWARDED A DEGREE / DIPLOMA

    REFERENCES

    List name and telephone number of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three. (3) school or personal references who are not related to you.

    NAME

    ADDRESS

    RELATIONSHIP

    TELEPHONE NUMBER

    YEARS KNOWN

    List Licenses and/or Certifications that may qualify you as being able to perform job-related functions in the position for which you are applying.

    LICENSES/CERTIFICATIONS

    EXPIRATION/RENEWAL DATE

    List special accomplishments, publications, awards. (Exclude information which would reveal sex, race, religion, national origin, age, ancestry, handicap or other protested status.)

    List any additional information you would like us to consider.

    Upload Resume.

    It is understood and agreed that a misrepresentation by me in this application will be sufficient cause for cancellation of the application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary. This application does not constitute an agreement or contract for employment for any specified period or definite duration.

    I give the Employer the right to investigate all references and to secure additional information about me, if job related to verify the accuracy of the information contained in the application, resume and/or other information submitted by me for the Employer’s consideration. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

    The Employer is an equal opportunity employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

    I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

    Voluntary Self-Identification Affirmative Action Program Applicant Information Form

    The Allendale Association is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

    Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as a disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

    Please complete the information requested below. Thank you for your cooperation.

    Section 1: General Applicant Information

    Name

    Date

    Position Applied For:

    Section 2: Please check (4) all that apply (See next page for definitions)

    Race or Ethnic Identity

    Gender

    ** Veteran Status

    I do not wish to Self-Identify

    How did you hear of our opening?

    EEOC RACE/ETHNIC IDENTIFICATION CATEGORIES
    Hispanic or Latino
    A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

    White (Not Hispanic or Latino)
    A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

    Black or African American (Not Hispanic or Latino)
    A person having origins in any of the black racial groups of Africa.

    Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
    A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

    Asian (Not Hispanic or Latino)
    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 Islands, Thailand, and Vietnam.

    American Indian or Alaska Native (Not Hispanic or Latino)
    A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

    Two or More Races (Not Hispanic or Latino)
    All persons who identify with more than one of the above five races.

    Special Disabled Veteran
    Defined as a veteran who is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability (I) rated at 30% or more, or (ii) rated at 10 or 20% in the case of a veteran who has been determined under Section 1506 to have a serious employment disability, or a person who was discharged from active duty because of a service-connected disability.

    Veteran of the Vietnam Era
    Defined as a veteran who (a) served on active duty in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (b) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released there from with other than a dishonorable discharge, or (c) was discharged or released from active duty for a service-connected disability if any part of his or her active duty was performed between August 5, 1964 and May 7, 1975.

    Other Eligible Veteran
    Defined as any veteran who served in a “war” declared by Congress, in a campaign or on an expedition for which a campaign badge, a service medal, or an expeditionary medal has been awarded.

    ALLENDALE ASSOCIATION
    P.O. Box 1088
    Grand Avenue & Offield Drive
    Lake Villa, IL 60046
    847-356-2351
    www.Allendale4kids.org