• APPLICATION FOR EMPLOYMENT

    The Milton Home - 206 East Marion Street - South Bend, IN 46601

  • Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of The Milton Home Human Resources Department at (574) 233-0165.

  • Date of Application*
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  • If you are under 18, and it is required, can you furnish a work permit?*
  • Have you ever been employed here before?*
  • Are you legally eligible for employment in this country?*
  • First date available for work*
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  • Type of employment desired (check all that apply):*
  • Preferred shift:*
  • Are you able to meet the attendance requirements of the position?*
  • Have you ever pled "guilty," or "no contest" to, or been convicted of, a crime?*
  • Drivers license state (if driving is an essential function)

  • EMPLOYMENT HISTORY - Employer #1

    Starting with your most recent employer, assignments, or volunteer activities, please provide the following information:
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  • Employed From*
     / /
  • Employed To*
     / /
  • Compensation*
  • May we contact them for reference?*

  • EMPLOYMENT HISTORY - Employer #2

    Starting with your most recent employer, assignments, or volunteer activities, please provide the following information:

  • IF NO SECOND EMPLOYER, PLEASE CLICK NEXT AT BOTTOM OF PAGE

  •  -
  • Employed From
     / /
  • Employed To
     / /
  • Compensation
  • May we contact them for reference?

  • EMPLOYMENT HISTORY - Employer #3

    Starting with your most recent employer, assignments, or volunteer activities, please provide the following information:

  • IF NO THIRD EMPLOYER, PLEASE CLICK NEXT AT BOTTOM OF PAGE

  •  -
  • Employed From
     / /
  • Employed To
     / /
  • Compensation
  • May we contact them for reference?

  • SKILLS AND QUALIFICATIONS

  • Software proficiency:

  • EDUCATIONAL BACKGROUND

    Starting with your most recent education, please provide the following information:
  • Level of completion*
  • Level of completion
  • Level of completion

  • REFERENCES

    Starting with your most recent reference, please provide the following information:
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  • APPLICATION STATEMENT

  • I certify that all information I have provided in order to apply for and secure work with the employer is true, complete, and correct (DO NOT SELECT UNTIL YOU HAVE READ THE STATEMENT).*
  • I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and education institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hearby waive any rights and claims I may have regarding this employer, its agents, employees and representatives, for seeking, gathering, and using such information in the employment process and all other persons, corporations, or organizations for furnishing such information about me (DO NOT SELECT UNTIL YOU HAVE READ THE STATEMENT).*
  • I understand that the employer does not unlawfully discriminate in employment, and no question on this application is used for the purposes of limiting or excusing any application from consideration for employment on a basis prohibited by applicable local, state, or federal law (DO NOT SELECT UNTIL YOU HAVE READ THE STATEMENT).*
  • I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will necessary to reapply and fill out a new application (DO NOT SELECT UNTIL YOU HAVE READ THE STATEMENT).*
  • If I am hired, I understand that I am free to resign at any time, with or without cause, and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral, or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president (DO NOT SELECT UNTIL YOU HAVE READ THE STATEMENT).*
  • I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard (DO NOT SELECT UNTIL YOU HAVE READ THE STATEMENT).*
  • I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered (DO NOT SELECT UNTIL YOU HAVE READ THE STATEMENT).*
  • I CERTIFY THAT I HAVE READ, FULLY UNDERSTAND, AND ACCEPT ALL TERMS OF THE FOREGOING APPLICANT STATEMENT.*
  • Signature*
  • Date*
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  • Should be Empty: