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Question	Answer
Form Name	Miss Punch Application
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	miss punch, i forgot my out punch how to write a letter to hr dept, punch missing application, miss punch application

12

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Application Instructions

INSTRUCTIONS FOR COMPLETING APPLICATION

Application Form: Please complete all sections on this form. Please be specific about your availability. Generally, shifts at our residential facilities are 7-3 pm, 3-11 p.m., 11-7 a.m. or 7:00 - 7:00 or 8:00 - 8:00. Always sign and date the application.

General Release Form: This form allows DSN to obtain general information from previous employers, schools, law enforcement agencies, and the Central Registries of Nebraska.

Family Care Safety Registry Form: To be considered an applicant for a position you must register with the Family Care Safety

Registry. You can access their website at: http://health.mo.gov/safety/fcsr/index.php.

We will review your application for the position(s) that you applied for. To be considered an applicant for a position, all sections of the application need to be complete. You must also meet the minimum qualifications and be available to work the scheduled hours of the position. Please read through the instructions carefully. If you have applied for more than one position, we will review your application for the position that best fits your skill set, hours and shift that you are available to work.

Interviews will be scheduled with those applicants that best meet the requirements for the position. You will be contacted by phone if you are selected for an interview. Many applications are received for each position and not all individuals are selected for interviews. Your patience is appreciated.

REQUIRED HIRING DOCUMENTATION

If you are hired by DSN the following documentation will be required at the time you complete your new hire paperwork.

Drivers License- current and valid,

Proof of Auto Insurance- current and valid for your personal vehicle

Education Documentation- high school diploma or GED; or a college level degree (Associates, Bachelors, Masters, Doctorate, etc.)

Second Form of Identification- social security card, passport, birth certificate, or any current and valid INS document for registered aliens

Payroll Direct Deposit Documentation- All DSN employees are required to have their paychecks directly deposited. Checking or savings accounts at most banking or credit unions are acceptable. For checking accounts a blank check will be needed. For a savings account either an account card or deposit slip with both the account and transit numbers will be needed. (A transit or routing number can be obtained from your bank).

TO SUBMIT YOUR APPLICATION:

Kansas City: Attention Glenna Love

Mail: Developmental Services of NE-MO, 1215 Swift Avenue, North Kansas City, MO 64116

FAX: 816-216-7786

Email: gdlove@dsnonline.org

 2011, Scott LeFevre, Revised 12/12/11

Mission

DSN supports persons, both children, and adults, with mental health issues and/or developmental disabilities gain skills, knowledge, and experience to increasingly use and benefit from the resources and settings available to all citizens in our community.

Principles

To fulfill its mission, the agency relies on seven principles:

−Every person has value.

−Every person will be treated with dignity and respect.

−Every person is capable of growth and learning through community experiences.

−Every person will experience life in the most natural and normal of settings.

−Every person has the right to be the primary decision maker in his/her own life and carries the responsibility for the direction it takes.

−Every person is protected by full weight of the U.S. constitution and its Amendments.

−Every person will be considered for participation in the program without regard to race, color, national origin, marital status, religion, creed, handicap, age, sex, or sexual orientation.

Goals

*The agency will strive to provide the nature and caliber of services that are requested by our consumers and their families.

*The agency will facilitate the use of community resources and promote individual empowerment thereby reducing reliance on agency provided services and facilities.

*The agency will encourage people to make informed decisions and experience the resulting outcomes.

*The agency will strive to be a vehicle, which enables individuals with developmental disabilities to fully participate in all areas of interest to them.

*The agency will maintain a service delivery system that is responsive and accountable to people with developmental disabilities and to the public.

*The agency will not rely exclusively on traditional service models when developing systems and procedures, but will attempt to provide services designed specifically to meet the needs, interests and desires.

Application for Employment

Please Print

Last Name			First Name						MI	Social Security Number

Present Address			City				State			Zip

Permanent Address			City				State			Zip

Phone Number			Referred by				Email
(	)

Position Desired		Date Available To Start				Salary/Wage Desired

Are You Currently Employed?		If so, may we contact your current employer?
Yes	No	Yes		No
Have you ever applied to this company before?					If yes, Where?			When?
Yes	No

General Information

List areas of special study/research, special training/skills, and/or volunteer experience related to the positions for which you have applied

Are you at least 19 years of age or older?		Yes	No

Do you have a valid Drivers License?	Yes	No	If yes, which state?

Do you have current auto insurance with state minimum coverage?				Yes	No

Do you have reliable transportation which can be used to safely transport individuals in services?							Yes	No

Can you provide documentation proving your eligibility to work in the U.S.?					Yes	No

Do you have an active checking or savings account for direct deposit?				Yes		No

If “No” to any of the above, please explain

Please list any minor traffic violations in the last three (3) years:

Have you ever been convicted of a felony?		Yes	No Misdemeanor?		Yes	No (A conviction record will not necessarily bar

employment.) If you answered “yes”, please fully describe the criminal conviction(s), listing the nature of the offense, disposition and date of disposition, your age at the time of the offense, and your rehabilitation since the conviction(s)

Have you completed High School \ GED:		Yes	No

Have you completed AA degree:	Yes	No	If yes, course of study:	If applicable, expected completion date:

Have you completed BA degree:	Yes	No	If yes, course of study:	If applicable, expected completion date:

Have you completed MA degree:	Yes	No	If yes, course of study:	If applicable, expected completion date:

References: Please give the names of two or more persons (not relatives or former employers) who have known you for one year or more, and whom we can contact.

Name

Address

Name

Address

City, State, Zip

Years Known

Phone

City, State, Zip

Years Known

Phone

(

)

(

)

Are you seeking

Full-Time

or

Part-Time employment?

When are you available to work?

Overnights Awake

Overnights Asleep

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

From

From

From

From

From

From

From

To

To

To

To

To

To

To

You will be required to attend training Monday - Friday. Pre-service training must be completed within 90 days of hire. Training times will vary but may occur in the morning, afternoon or evening hours. Do you have a conflict that would prevent you from attending these

specific training times?

Yes

No If yes, please explain:

 2012, Scott LeFevre, Revised 2/23/12

Applicant Name___________________________________________

Former Employers: List below all present and past employment beginning with your most recent, accounting for all time since leaving High School, or the last seven years. Please DO NOT leave the phone number blank.

Company Name

Address

City

State

Phone

Position Title

฀ Full-time

฀ Part-time

(

)

Duties

Employment Start Date

Employment End Date

Starting Salary

Ending Salary

Supervisor Name

Reason for Leaving

Shaded Section is for Office Use Only

Verified ฀

Is this employee eligible for re-hire? ฀ Yes ฀ No

Additional Comments:

If completed by phone, name of contact person

Title of contact person

DSN representative completing reference

Date

Company Name

Address

City

State

Phone

Position Title

฀ Full-time

฀ Part-time

(

)

Duties

Employment Start Date

Employment End Date

Starting Salary

Ending Salary

Supervisor Name

Reason for Leaving

Shaded Section is for Office Use Only

Verified ฀

Is this employee eligible for re-hire? ฀ Yes ฀ No

Additional Comments:

If completed by phone, name of contact person

Title of contact person

DSN representative completing reference

Date

Company Name

Address

City

State

Phone

Position Title

฀ Full-time

฀ Part-time

(

)

Duties

Employment Start Date

Employment End Date

Starting Salary

Ending Salary

Supervisor Name

Reason for Leaving

Shaded Section is for Office Use Only

Verified ฀

Is this employee eligible for re-hire? ฀ Yes ฀ No

Additional Comments:

If completed by phone, name of contact person

Title of contact person

DSN representative completing reference

Date

AUTHORIZATION: “I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.” “I AUTHORIZE INVESTIGATIONS OF ALL STATEMENTS CONTAINED IN THE APPLICATION AND THE REFERENCES AND AUTHORIZE EMPLOYERS LISTED ABOVE TO GIVE YOU AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND UTILIZATION OF SUCH INFORMATION.” “I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME OR MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.”

Signature of Applicant	Date

Contingency Statement

By signing below I am stating that I understand the following:

If I am offered a position by Developmental Services of Nebraska-MO, Inc., any offer of employment is contingent upon the following; including but not limited to:

Department of Motor Vehicles driving record check

Office of Inspector General Check

Excluded Parties List System

Missouri Family Care and Safety Registry Background Screen

•State Criminal History Records

•Sex Offender Registry

•Child Abuse/Neglect Registry

•Employee disqualification list

•Employee disqualification registry

•Child Care licensing records

•Foster Parent licensing records

I authorize my employer to obtain criminal history record information checks from any law enforcement agency, including the Federal Bureau of Investigation. If I so choose I may obtain a copy of the results directly from my employer.

_____________________________________________________	__________
Print Name	Date
_____________________________________________________
Signature
_____________________________________________________	__________
Witness Signature	Date

 2011, Scott LeFevre, Revised 10/26/11

Applicant Consent for Release of

Information

This form must be completed in its entirety. Enter NA for any items that may not be applicable.

1. I,

, agree to give Developmental Services of Nebraska-MO, Inc.

print or type name

(hereafter referred to as DSN-MO) permission to request and receive information about me from the Missouri Family Care Registry, Missouri Department of Motor Vehicles, Missouri State Patrol, Federal Bureau of Investigation, Office of Inspector General, Excluded Parties List System and Missouri Sex Offenders Registry. Copies of any information or reports, if any exist, may be released to DSN.

2.I authorize each and every former employer, school, individual agency, organization, or law enforcement agency to release any information requested by DSN in connection with the position for which I am applying. I herewith hold such persons harmless for releasing such information that is within their knowledge or records.

3.The following information is required for identification purposes only

List any other names used by you under which records may be filed (print or type)

Date of Birth (m/d/y)

Gender Male

Female

Social Security Number

Signature

Date

.

2011, Scott LeFevre, Revised 10/26/11

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