Employment Application

Position Applying For*

Type of Employment*

Full-Time

Part-Time

Sub

Temp

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Were you previously employed with DICSA*

Yes

When where you employed with DICSA?*

Have you been convicted of a felony in the last seven (7) years?*

(Such conviction may be relevant if job related, but does not bar you from employment.)

Yes

If you answered yes to the conviction of a felony, please explain*

Does DICSA currently employ anyone related to you?*

Yes

If yes, what position does that person hold?*

WORK EXPERIENCE

Company 1

Company Name*

May we contact this employer?*

Yes

Company Phone*

Superviser's Name*

Start Date*

End Date*

Ending Wage*

Why did you leave this employer?*

Company Job Titles/Duties*

Company 2

Company Name

May we contact this employer?

Yes

Company Phone

Superviser's Name

Start Date

End Date

Ending Wage

Why did you leave this employer?

Company Job Titles/Duties

Company 3

Company Name

May we contact this employer?

Yes

Company Phone

Superviser's Name

Start Date

End Date

Ending Wage

Why did you leave this employer?

Company Job Titles/Duties

EDUCATION

School 1

School Name*

School City, State and Zip*

School Degree*

Are you currently attending this school?*

Yes

Number of years attended*

Did you graduate?*

Yes

School 2

School Name

School City, State and Zip

School Degree

Are you currently attending this school?

Yes

Number of years attended

Did you graduate?

Yes

School 3

School Name

School City, State and Zip

School Degree

Are you currently attending this school?

Yes

Number of years attended

Did you graduate?

Yes

PROFESSIONAL REFERENCES

List individuals who are not related to you and who are able to evaluate your professional knowledge and ability. These may be individuals from your past and/or current employers.

Reference 1

Name*

First Last

Phone*

Email*

Reference 2

Name*

First Last

Phone*

Email*

Reference 3

Name*

First Last

Phone*

Email*

IMPORTANT, PLEASE READ CAREFULLY

Applicant/Employee Verification, Authorization and Release

I authorize DICSA to investigate all statements contained in this application (and accompanying resume, if any). I also authorize DICSA to conduct a background check which may include, without limitation, contacting past employers and references, conducting an investigation of my personal history, a Department of Human Services Clearance, a National Sex Offenders Registry Clearance and a criminal background check.

I understand that applicants who misrepresent or omit any material facts on this application or during any subsequent interview may not be hired or if hired, and found to have made a misrepresentation may be terminated immediately and I agree that DICSA shall not be held liable in any respect if I am not hired or terminated for that reason. If employed, I agree to observe all rules, regulations, policies and procedures of DICSA.

All DICSA employees are at-will employees.

Neither this employment application nor any of the company’s policies or procedures shall be considered a contract or guarantee of employment or continuation of employment. I understand this application is only current for 180 days. At the conclusion of this time, if I have not heard from DICSA and still wish to be considered for employment, it will be necessary to update this application.

By checking this box:*

I agree to the above

Signature*

Name

This field is for validation purposes and should be left unchanged.

Online Employment Application

WORK EXPERIENCE

Company 1

Company 2

Company 3

EDUCATION

School 1

School 2

School 3

PROFESSIONAL REFERENCES

Reference 1

Reference 2

Reference 3

IMPORTANT, PLEASE READ CAREFULLY