Employment Form Deaf Independent Living Association, Inc.AboutEmployment OpportunitiesEmployment Form Thank you for your submission. Equal Opportunity Employer: Deaf Independent Living Association, Inc. is an equal opportunity employer. Personal Information Please enter your Position Applying for*. Please enter your First Name*. Please enter your Last Name*. Please enter your E-mail*. Prior Contact With DILA Have you ever applied to DILA before? Please Select Yes No If yes, what position did you apply for and when? Have you ever worked for DILA before? Please Select Yes No What position did you hold and when was your last day? Education Are you fluent in American Sign Language? Yes No Special skills, training, etc.? Employment History Employer 1 Rate of Pay at Departure Name Of Immediate Supervisor May we contact your employer? Please Select Yes No Employer 2 Rate of Pay at Departure Name of Immediate Supervisor May we contact your employer? Please Select Yes No Employer 3 Rate of Pay at Departure Name of Immediate Supervisor May we contact your employer? Please Select Yes No References List business or professional persons known, but not related to you for at least three years. Reference 1 Reference 2 Reference 3 Conviction Record Have you ever been convicted of a felony or crime of violence, or pleaded no contest in a felony, or been convicted of a misdemeanor resulting in imprisonment or a fine over $500 during the last ten years? (Conviction will not necessarily disqualify applicant but failure to disclose this information could result in immediate termination.) Have you ever been convicted of a felony or crime of violence? Please Select Yes No If 'Yes', please explain: Military Service Record Were you in the U.S. Armed Forces? Please Select Yes No If 'Yes', what Branch? Dates of Duty (To & From)? Type of discharge? U.S. Citizenship Are you legally eligible for employment in the United States? Please Select Yes No If 'Yes', Alien Registration Number: The above information is true and complete to the best of my knowledge. Should I be employed by the Agency, any misrepresentation or false statement contained herein may be considered cause for possible dismissal. The Agency has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior employment, personal history or credit standing and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me. I reserve the right to know the names and addresses of any investigative agencies used in order that I may learn the information contained in any reports furnished to the Agency. I understand that this application does not constitute an employment contract of any kind. Should I be employed by the Agency, I may resign such employment at any time at my discretion with or without prior notice and the Agency may terminate my employment at any time at their discretion, with or without cause and without prior notice. I understand that it is DILA’s policy to run background and MVA checks on all applicants. Do you agree to the terms above? I Agree I Do Not Agree Please select an option above. Today's Date: Submit
