Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, handicap, veteran status, marital status, sexual orientation, or any other characteristic protected by law. We are an equal opportunity employer.
The form entry descriptions in Purple text are required from all applicants. |
| First Name: | | Last Name: | |
| Address: | |
| City: | | State: | |
| Zip: | | Phone: | |
| E-mail: | | Alternate Phone: | |
| Desired Position: | Click here to view posted job descriptions. |
| If Other: | |
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Employment History
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| Please list chronologically, beginning with most recent experience. |
| Employer 1: | | Address/City: | |
| From (MM/YYYY): | | To (MM/YYYY): | |
| Supervisor: | | Phone: | |
| Status | |
| Job Duties: | |
| Reason for Leaving: | |
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| Employer 2: | | Address/City: | |
| From (MM/YYYY): | | To
(MM/YYYY): | |
| Supervisor: | | Phone: | |
| Status: | |
| Job Duties: | |
| Reason for Leaving: | |
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| Employer 3: | | Address/City: | |
| From (MM/YYYY): | | To
(MM/YYYY): | |
| Supervisor: | | Phone: | |
| Status: | |
| Job Duties: | |
| Reason for Leaving: | |
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Education
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Personal Information
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| Are you legally authorized to work in the U.S.?: (If hired, you will be required to provide proof of work authorization.) | Yes No |
| Are you at least 21 years of age? | Yes No |
| Briefly describe skills you may have that you acquired in other employment or armed forces: |
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| If you are an experienced operator of any office machines or equipment, please list: |
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Typing speed? | WPM | Shorthand? | WPM |
| If you are experienced operator of any machines or equipment, please list: |
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| Do you have any other skills you wish to mention? |
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| Are you presently employed? | Yes No |
| If so, may we contact your present employer? | Yes No |
| If hired, when would you be available to start? | |
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Background Information
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| SIRSS seeks individuals for employment who will be role models. SIRSS is also concerned with providing a safe environment. As a consequence, SIRSS has determined that it is not only its right, but its duty as well, to obtain information on an applicant's criminal conviction record. A conviction will not automatically disqualify an applicant for consideration unless it is one for which employment is prohibited by Illinois code. Excluding minor traffic violations such as speeding, etc., state whether or not you have been convicted of a crime. If your answer is yes, please describe below: |
| Type of Offense | When | County and State |
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| If you have a criminal record (a conviction), please explain: |
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| Note: A conviction record will not necessarily be a bar to employment, and factors such as age, and time of the offense, seriousness and nature of the violation, and rehabilitation, will be taken into account unless the conviction is one for which employment is prohibited by the Illinois Code: (105 ILSC 5/10-21.9). |
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Professional References
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| List individuals familiar with your job qualifications. SIRSS reserves the right to confer with persons listed by you as a reference, or with any other individuals, with knowledge concerning your total qualifications for the position. SIRSS will not inquire into your financial status, religious affiliation, marital status, or on other matters unrelated to your qualifications to fill the position for which you apply. Information received from such inquiries will be used solely for determining your employment with SIRSS and for no other purpose. This information will not be shared with anyone other than those representatives involved in the selection process. Unless you are willing to authorize SIRSS to make such inquiries, your application will not be considered. In submitting this application, you agree to these terms and conditions. |
| 1) Name of Reference: | | 2) Name of Reference: | |
| Occupation: | | Occupation: | |
| Address: | | Address: | |
| City/State/Zip: | | City/State/Zip: | |
| Phone: | | Phone: | |
| Relationship: | | Relationship: | |
| How long known: | | How long known: | |
| Applicants may optionally paste into the space provided below a plain TEXT formatted resume: |
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Invitation to Identify for Affirmative Action Purposes
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Southern Illinois Regional Social Services, Inc., in accordance with State and Federal laws, does not discriminate on the basis of age, race, religion, color, sex, national origin, marital status or disability.
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| Indicate your gender: | |
| Indicate your appropriate race/ethnic group: | |
| How were you referred to this job? | |
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Certification
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| By selecting the appropriate certification option below, you certify that all statements made by you on this electronic application are true and complete and to the best of your knowledge and that you have withheld nothing that would affect the application unfavorably. By the choice of certification selection below, you acknowledge that you understand that misrepresentations or omissions may be a cause for rejection, or may be cause for subsequent dismissal if you are hired. |
