Application for Employment

* Required fields are marked with an asterisk.

Date: 11/21/2024

Last Name: *

First Name: *

Middle Name:

Street: *

City: *

State:

Zip code:

Phone: *

Email: *

Date Available:

Position applying for:

Hourly rate expected:

Will you accept part-time (less than 40 hours/week)? *

Yes No

Do you have a valid Montana Driver License? *

Yes No

If hired can you show proof of authorization to work in the U.S.? (Verification will be required.) *

Yes No

Have you been employed here before? *

Yes No

If yes, give dates:

Education

(All education listed will be confirmed with the school(s).)

High School/GED

Name & Location: *

Course of Study:

Graduate? *

Yes No

College/University

Name & Location:

Course of Study:

Graduate?

Yes No

Business/Vocational

Name & Location:

Course of Study:

Graduate?

Yes No

Graduate/other

Name & Location:

Course of Study:

Graduate?

Yes No

Training

Describe any other training (workshops/seminars) you have completed that will qualify you:

Employment Experience

Start with your present or last job and go back five (5) years, listing former employers. You may include military service assignments and volunteer activities.

1.

Employer: *

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving: *

Start date: *

Initial Pay Rate:

End date: *

Final Pay Rate:

Work Performed:

2.

Employer: *

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving: *

Start date: *

Initial Pay Rate:

End date: *

Final Pay Rate:

Work Performed:

3.

Employer:

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving:

Start date:

Initial Pay Rate:

End date:

Final Pay Rate:

Work Performed:

4.

Employer:

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving:

Start date:

Initial Pay Rate:

End date:

Final Pay Rate:

Work Performed:

Professional References

Most recent supervisors or instructors are required. Do not list friends or relatives.

1.

Name *:

Phone:

Street:

City:

State:

Zip code:

2.

Name *:

Phone:

Street:

City:

State:

Zip code:

3.

Name *:

Phone:

Street:

City:

State:

Zip code:

Ability

Can you perform all the essential functions of the position for which you are applying with or without a reasonable accommodation? *

Yes No

Please explain:

Supplemental Background Information

1. Have you ever been convicted for neglect or abuse, sexual abuse, or other acts of violence? *

Yes No

2. Are you currently being investigated for neglect or abuse of any kind? *

Yes No

3. Have you ever been terminated from any job for any reason other than a layoff? *

Yes No

Please provide dates and explanations for any "YES" answers to the last three questions.

Background Information Release

Have you ever been convicted of any criminal offense, either misdemeanor or felony? *

Yes No

If yes, please explain:

Do you have any tickets on your driving record? *

Yes No

If yes, please explain:

I give Quality Life Concepts my permission to conduct a background investigation. I hereby authorize any law enforcement agency and/or child protection agency to release any records they have regarding me to Quality Life Concepts. I understand that my potential employment is contingent upon these reports. A photocopy of this form is as valid as the original. *

I authorize Quality Life Concepts to obtain a copy of my motor vehicle record to evaluate my insurability or for other permissible uses related to my application. If I am hired for employment by Quality Life Concepts, I hereby authorize Quality Life Concepts to procure these records on a periodic basis or as deemed necessary to evaluate my continuing insurability. *

The following information is needed for the background check and the motor vehicle check.

Date of birth: *

Social Security Number:

Full name given at birth: *

Driver License Number:

Driver License State:

Please download the State of Montana Release of Information Form (PDF). The form can be filled electronically, but must be printed and notarized. Our office has notaries available. Please deliver the printed, notarized form to our office.

Agreement

I hereby authorize Quality Life Concepts, Inc. to inquire as to my record with any or all of my former employers with no liability arising therefrom. I hereby certify that all information above is true and complete to the best of my knowledge. I am aware that falsification or misrepresentation of required information is grounds for dismissal or disqualification from employment with Quality Life Concepts, Inc. *

I understand that if I am employed by Quality Life Concepts, Inc. the agency may change wages, benefits, and conditions at any time and that there is no guarantee of permanent employment. *

I understand if I am applying for a direct care provider position in Great Falls, I must attend Quality Life Concept’s pre-employment session which takes place every Tuesday at 10:00am at their office, located at 215 Smelter Avenue NE, Great Falls, MT 59404.*

Comments

Please list any additional comments or special qualifications you would like to be considered:

Submit

Application for Employment

Education

High School/GED

College/University

Business/Vocational

Graduate/other

Training

Employment Experience

1.

2.

3.

4.

Professional References

1.

2.

3.

Ability

Supplemental Background Information

Background Information Release

Agreement

Comments

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