MYEP Application for Employment

407 Highland Court, Iowa City, IA 52240 - PHONE 319-341-0060 - FAX 888-883-1235 www.myep.us

MYEP is a non-profit organization dedicated to providing advocacy and person-centered services which facilitate personal growth and community inclusion to people with disabilities.

PERSONAL INFORMATION

First Name *

Last Name *

Maiden Name or other names you've gone by (if applicable)

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

EMPLOYMENT BEING SOUGHT

Position(s) desired:

Do you desire full or part time employment?

Full Time

Part Time

Full Time or Part Time

If part time, how many hours per week do you desire?

Please specify hours you are available to work for each day of the week?

	-
Sunday	-
Monday	-
Tuesday	-
Wednesday	-
Thursday	-
Friday	-
Saturday	-

How did you learn about MYEP?

If referred by a current employee please list that employees first and last name. (limit 1) 🛈

EDUCATION HISTORY

High School Diploma or Equivalent is required

Name of High School *

Last Year Completed

1

2

3

4

City/State

Did you Graduate? *

Yes

No

Name of College

Last Year Completed

1

2

3

4

City/State

Did you Graduate?

Yes

No

Degree Earned

Business, Vocational, or Graduate

Last Year Completed

1

2

3

4

City/State

Did you Graduate?

Yes

No

Degree Earned

Other

EMPLOYMENT/ VOLUNTEER HISTORY

(List in order beginning with the most recent)

Company Name/ Type of Business *

Telephone

Company Address

Dates of Employment

	-
From: MM/YYYY	-
To: MM/YYYY	-

Name of Supervisor

Position Held

Full Time or Part Time

Full Time

Part Time

Brief Description of Duties *

Company Name/ Type of Business

Telephone

Company Address

Dates of Employment

	-
From: MM/YYYY	-
To: MM/YYYY	-

Name of Supervisor

Position Held

Full Time or Part Time

Full Time

Part Time

Brief Description of Duties

Company Name/ Type of Business

Telephone

Company Address

Dates of Employment

	-
From: MM/YYYY	-
To: MM/YYYY	-

Name of Supervisor

Position Held

Full Time or Part Time

Full Time

Part Time

Brief Description of Duties

ADDITIONAL INFORMATION

If desired, provide additional information regarding your qualifications, skills, experience, education, background, and interest that you believe realte to the position you are applying for.

REFERENCES

(please provide names of three references you've known for at least three years and who are not related to you)

* 🛈

	Name	Phone/Email	Relationship to reference
1	Name	Phone/Email	Relationship to reference
2	Name	Phone/Email	Relationship to reference
3	Name	Phone/Email	Relationship to reference

BACKGROUND INFORMATION

Have you been convicted of a
crime in this or any other state?
(Including deferred judgment) *

Yes

No

If yes, list all convictions and explain. A
conviction in itself amy not prohibit
employment. Each conviction is considered
on the merits of recency, circumstances, and severity.

Do you have a record of founded child
or dpendent adult abuse in this or
any other state? *

Yes

No

Are you the subject of any current/open DHS investigations? *

Yes

No

Are you excluded or disqualified by the Office
of the Inspector General (OIG) for participation
in medicare/medicaid? *

Yes

No

This agency will perform background checks with the Department of Criminal Investigations, child and dependent adult abuse registries, and the OIG. A post-employment discovery of a conviction and/or abuse information not provided on the application will likely lead to termination of employment with MYEP. It is a requirement that all employees self-report convicitons or abuse charges which occur while employed with the agency. Failure to do so will lead to disciplinary action, likely termination of employment.

DRIVER'S LICENSE INFORMATION

Do you have a
valid driver's license? *

Yes

No

If yes: State of Issue

Driver's License #

A valid driver's license and a driving record that is acceptable from a risk management perspective may be required for employment at MYEP, or may restrict the postion/location able to be offered.

ESSENTIAL FUNCTIONS

Are you willing and/or able, with or without reasonable accommodations to perform the following duties?

Work with the individuals who may need
assistance with self-care such as bathing? *

Yes

No

Work with individuals who may display challenging
behaviors such as verbal or physical aggression? *

Yes

No

Provide physical assistance such as
lifting and repositioning individuals? *

Yes

No

APPLICANT ACKNOWLEDGEMENT

I certify that all information provided on this employment application is true and complete. I understand that misrepresentation or omission of facts will result in this application not being considered, or if hired, will result in disciplinary action up to and including termination of employment.

I authorize investigation of all information provided on this application. I authorize any person, school, current and former employers, and any other organization or agency to provide any information relevant to investigation of this application. I hereby release them from all liability or responsibility to me for doing so.

I understand that, if accepted for employment, I shall be required to provide proof of identity and eligibility to work in the United States (in compliance with the Immigration Reform & Control Act of 1986), as a condition of employment.

I understand that, in accordance with the Iowa Smokefree Act, that MYEP prohibits smoking except in authorized outdoor areas.

I understand and agree that employment with MYEP is “at will” and is therefore for no definite period and may, regardless of the date of payment of my wages, be terminated at any time without any previous notice (unless otherwise required by law).

If employed by MYEP: I will faithfully, diligently, and to the best of my ability perform duties of employment and accept and obey rules, regulations, provisions, policies and procedures issued, or to be issued by MYEP.

MYEP is an equal opportunity employer commited to employing a diverse workforce. MYEP considers applicants without regard to race, color, age, sex, religion, national origin, sexual orientation, marital or veteran status, the presence of a non-job related medical condition or disability, or on any other basis prohibited by federal, state, or local laws.

I have read and hereby affix my signature as verification of the the foregoing statements and all information provided on this application.

Acknowledgement Required *

I have read and hereby affix my signature by clicking this box as verification of the foregoing statements and all information provided on this application

Please submit a copy of your resume or cover letter.