Developmental Services of Northwest Kansas, Inc. Application for Employment
Last Name:	First Name:	Middle Name:
Address:	City:	State:
Zip:	Home Phone:	Work Phone:
Position(s) applied for:
Location(s) you are interested in working: (Check all that apply) Hays Victoria Russell Atwood Colby Hoxie Ellis Stockton Hill City Norton Oakley
Are you related to a current employee of DSNWK?
Yes No Unknown	Who?	Relationship:
Are you related to a County Commissioner, Board Member, Person Served or Parent of a Person Served by DSNWK?
Yes No Unknown	Who?	Relationship:
Have you filed an application with DSNWK before? Yes No
Have you ever been employed in any branch of DSNWK? Yes No		Where?
Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? Yes No
Have you been convicted of a felony or released from prison in the past ten years? Yes No If Yes, Please explain:
Is adequate transportation available so you can get to work on time every day? Yes No
When are you available to work? Check all that apply. FT PT SUB Nights
Hours you are available to work:
Sunday	Not Available
Monday	Not Available
Tuesday	Not Available
Wednesday	Not Available
Thursday	Not Available
Friday	Not Available
Saturday	Not Available
Can you travel if the job requires it? Yes No
Summarize special skills, training, or other qualifications of value for the job which you have applied?
Were you referred to DSNWK by a current Employee? Yes No Employee's Name:

Education
School	Name, City, State	Did you graduate?	Status/Degree Received
High School		Yes No
Undergraduate College		Yes No
Graduate/Professional		Yes No
Other (Specify)		Yes No

References
Name	Title	Phone Number

Experience (Employment History: Please include your last three employers, assignments, or volunteer activities, starting with the most recent, including military experience. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected areas.)
Employer:	Phone:	Employed From (mm/dd/yyyy)	Employed To (mm/dd/yyyy)
Address:	City:	State:	Zip:
Job Title:	Supervisor and Title:	Hourly Rate/Salary Beg:	Hourly Rate/Salary End:
Work Performed:	Reason for Leaving:	May we contact for reference? Yes No

Experience
Employer:	Phone:	Employed From (mm/dd/yyyy)	Employed To (mm/dd/yyyy)
Address:	City:	State:	Zip:
Job Title:	Supervisor and Title:	Hourly Rate/Salary Beg:	Hourly Rate/Salary End:
Work Performed:	Reason for Leaving:	May we contact for reference? Yes No

Experience
Employer:	Phone:	Employed From (mm/dd/yyyy)	Employed To (mm/dd/yyyy)
Address:	City:	State:	Zip:
Job Title:	Supervisor and Title:	Hourly Rate/Salary Beg:	Hourly Rate/Salary End:
Work Performed:	Reason for Leaving:	May we contact for reference? Yes No

Terms and Conditions

Many positions at DSNWK require the operation of a company vehicle. Insurance regulations disqualify those with three moving violations or an alcohol/drug related traffic violation within the last year from this requirement. DSNWK will perform a post-offer driver's license check if job related.

I understand and agree that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or seperation from the employer's service if I have been employed.

I give DSNWK the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability DSNWK and its representatatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.

DSNWK, Inc. is an Equal Opportunity Employer. DSNWK does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment ona a basis prohibited by local, state or federal law.

I understand that just as I am free to resign at any time, DSNWK reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of DSNWK has the authority to make any assurances to the contrary.

I agree to submit to background checks (screen now, SRS, KDHE, etc.) deemed necessary by DSNWK if hired. I understand I may be required to submit to a pre-employment alcohol and drug test if hired in a safety sensitive position.

Applications will remain active for 90 days, but kept on file for one year. Applicants may reactivate their application for an additional 90 days by contacting the Human Resources Dept. Applications are destroyed after 1 year.

I agree to the terms and conditions on this application Yes No