RSI Part-Time Employment Application

Dear Applicant:

Welcome to Residential Services, Inc.  We appreciate your interest in our organization.

Residential Services, Inc., is an Equal Opportunity Employer.  Through its Policies and Procedures Manual and EEO-1 statistical reports, RSI is proud to reaffirm its commitment to equality of opportunity and pledges that it will not practice or permit any form of discrimination in employment on the basis of race, color, religion, gender, national origin, age, disability, or sexual orientation.  We believe that diversity helps us build a stronger and more vital organization.

As you complete your application, it is very important that you answer all questions completely and accurately.  We use the information that you provide to help make our hiring decisions.  If you provide erroneous, incomplete, or misleading information and are hired, you can be terminated for falsifying your application.  We will be contacting your references, employers, and schools, as well as conducting criminal record checks.  You will also be required to have a drug screening.  We take these measures in compliance with governmental regulations in order to ensure the best possible staff and to ensure the safety and well being of our residents and staff.

 Thank you for your interest in our program.

 Sincerely, 

Dennis Bradshaw
Executive Director

Important Instructions!  While completing the application, use your mouse and/or the TAB key to navigate from one field to the next.  If you press the ENTER/RETURN key before you are done, the application will submit itself and you will have to go back and start over!  When you are finished filling everything out, use the SUBMIT button at the bottom to send in your application, thanks!

 

I. Personal Information
Name:
(As on Social Security Card)		   
Home Telephone
Business Telephone
Cell Number
Email Address (if you don't have an email address, enter 'none')
Address
City, State, ZIP Code


II. Job Requirements

This application will be considered only for the specific position for which it has been submitted. Once that particular opening has been filled, the application will not be considered for future openings unless the applicant submits in writing a request for each specific opening he or she is interested in. Applications for employment will be kept on file for one year should applicants wish to reactivate them.
Which position are you applying for?
If you picked 'Other', please specify the opening you are applying for (should correspond to one of our Current Openings):
Application is for:
Will you accept employment requiring:
Night Work Yes No
Weekend Work Yes No
Rotating Shifts Yes No
Overtime Yes No
Date available for work:
Minimum Salary Acceptable: $
Have you submitted an 
application in the past?
Yes No
Are you currently at least 18 years old?
Yes No
Where did you learn about RSI?
If you indicated either a university or
'other', please specify
If you were referred by a current RSI
employee, please enter their name:

Part-time employees are required to work a minimum of least 20 hours per pay period (every two weeks).  The following are scheduling options for part-time positions.  If the option you select is not currently available, you may need to select a different option.  You may choose another option after 3 months.  Schedules may be subject to approval by a director. This form should be completed with the HR Specialist.

 

Check 1 of the following options to meet the minimum part time requirement:

Option 1. Morning Shifts (hours vary between 6am-9am, Monday-Friday)
Option 2. Awake Third Shift (at least 2 third shifts per pay period)
Option 3. Weekend - Check one of the following:
  Every Saturday
  Every Sunday
  Every other Saturday and Sunday (Min. 20 hrs/weekend, varies between homes)
Option 4. Directions:    Check enough boxes in 2 of the 3 categories below to total minimum of 20 hrs in 2 weeks.  If Categories A or C are chosen, write in days of the week.

Category A: Morning Shifts (hours vary between 6am-9am, Monday-Friday)

2 Morning Shifts    
3 Morning Shifts  
4 Morning Shifts
Other

Category B: Weekend Shifts (hours vary Friday 3pm-Sunday 11pm)

 Every Friday evening
 Every other Saturday
 Every other Sunday
 Every other Saturday & Sunday (less than 20 hrs/weekend)
Other

Category C: Weeknights (hours vary between 2-11pm, Monday-Thursday)

2 Weeknight Shifts    
3 Weeknight Shifts  
4 Weeknight Shifts
Other


III. General Information
Are you legally permitted to work in the U.S.? (Evidence of this will be required if you are hired.)
Yes No
Are you able to perform the responsibilities of this position (e.g., driving, dealing with aggressive behavior, lifting and transferring residents) with or without reasonable accommodation?
Yes No
If you require accommodations, what would be these be, and how would you perform the responsibilities?
Military Service: Are you a veteran?
Yes No
Dates of Service:
We are required by the state to ask:
Are you required to register for the Selective Service?
Yes No
If Yes, are you registered?
Yes No
Please explain if you are required to register, but have not done so.
We are required by the state's Division of Facility Services to conduct criminal records checks on our staff members. (This information will not necessarily result in denial of employment.)
Have you ever been convicted of or pled guilty to or no contest to any unlawful offense?
Yes No
Date of Conviction(s):
County & state where conviction(s) occurred:
If yes, please list convictions and/or guilty pleas.
Have you ever been convicted of child abuse, neglect or mistreatment or do you have a prior employment history of child abuse, neglect or mistreatment?
Yes No
If yes, explain below.
Do you currently have a chemical dependency on any substance? (This information will not necessarily result in denial of employment.)
Yes No
If yes, explain below.

Note: Successful completion of a pre-employment drug testing IS required for all RSI staff members.


IV. Education and Training
A. List last three schools attended and location, starting with present or most recent one.
B. List number of years completed.
C. Indicate degree or diploma earned, if any.
D. GPA and
E. Major field of study
A. School & Location (include City & State) B. No. of Years Completed C. Degree/Diploma D. Overall Grade Point Average E. Major/Field

Are you enrolled in school now?
Yes No
If yes, where:
Course of Study?
When do you anticipate finishing school?
Fields of work for which you are licensed, registered, 
or certified. Give date(s) and sources(s) of issuance.
If yes, where:
Do you have a driver's license?
Yes No
License Number:
State Issuing:
Do you have any points charged against your license?
Yes No
If yes, how many points and for what offense(s)?
Please choose any related skills you are 
proficient enough in to assist, lead or teach:
Fitness 
Sports
Fine Arts
Performing Arts
Lifeguard
Photography
Other (specify)


V. Employment Record
List your PRESENT or most recent employer FIRST. Include all employers, whether related to position applied for or not, and related unpaid volunteer experience.
Employer A
Title Supervisor's Name
Employer Address
Duties
Hours per week
Start Date (month/year) End Date (month/year)
Salary Reason For Leaving

Employer B
Title Supervisor's Name
Employer Address
Duties
Hours per week
Start Date (month/year) End Date (month/year)
Salary Reason For Leaving

Employer C
Title Supervisor's Name
Employer Address
Duties
Hours per week
Start Date (month/year) End Date (month/year)
Salary Reason For Leaving

Employer D
Title Supervisor's Name
Employer Address
Duties
Hours per week
Start Date (month/year) End Date (month/year)
Salary Reason For Leaving
Use the space to the right to provide any additional relevant work experience, or copy and paste your resume in plain text.
Have you ever been dismissed from a position or asked to resign from a position?
Yes No
If YES, then please explain:


VI. References
Please list three references, giving name, address, and phone number for each. Two of these must be work (i.e., supervisors) or school (i.e., a professor or teacher) related. The third may be a professional or personal reference. (No relatives.)
Reference A:
Reference B:
Reference C:
By clicking the 'Submit Application' button, I hereby certify that all statements on this application are true and complete to the best of my knowledge and belief. If employed, I understand that my falsification of this record may be considered cause for termination. I authorize persons, schools, current employer and any other organizations, agencies or employers to provide RSI with any relevant information needed to consider my employment. I understand that any offer of employment is conditional upon RSI receiving satisfactory verification of the information on this application.

I understand and agree that this employment application does not create a contract of employment, and that no representative of this company has the authority to make an oral contract of employment with me.

NOTE: This application will not be considered for any position unless it is entirely completed.