Illinois Mathematics and Science Academy

ILLINOIS MATHEMATICS AND SCIENCE ACADEMY

DEPARTMENT OF SECURITY

APPLICATION FOR EMPLOYMENT

I. General Information

A. Name in Full

Last Name: / First Name:
Middle Name: / State

B. Residence Address (Street, City, State, Zip):

C. Telephone Numbers:

Residence: / Business:
D. Are you 21 year of Age or Older? / Yes / No

E. Referral Source: (Circle One)

1. Advertisement / 4. Walk-in
2. Friends / 5. Employment Agency
3. Relatives / 6. Other (If other give details):

F. Employment Desired

Full-time

Part-time

Date Available

Are you employed now?

Yes

No

If yes may we contact your present employer?

Yes

No

G. Have you ever filled out an application here before? Yes No

H. Have you ever been employed here before? Yes No

I. Have you ever been convicted of a crime? Yes No

If yes give details and dates:

II. Citizenship Data

A. Are you either a U.S. citizen or an alien authorized to work in the United States? Yes No

B. / If you are an alien, give alien card number:

III. References

List three names, occupations, number of years known, addresses and telephone numbers of persons who are not relatives or former employers, who have known you well during the past five years.

Complete name:
Occupation: / Number of years known:
Residence Address
Telephone Number:
Complete name:
Occupation: / Number of years known:
Residence Address
Telephone Number:
Complete name:
Occupation: / Number of years known:
Residence Address
Telephone Number:

IV. Education

List the following information in the spaces provided.

Name of School / City, State /

Dates Attended

Diploma/Degree

To / From
High School
College
Trade School

V. Past and Present Employment

List chronologically your last five employers, starting with your most resent.

A. / Name, Address & Phone Number of Employer:
Date From: / To: / Position / Salary
Name of Supervisor:
Reason for leaving:
B. / Name, Address & Phone Number of Employer:
Date From: / To: / Position / Salary
Name of Supervisor:
Reason for leaving:
C. / Name, Address & Phone Number of Employer:
Date From: / To: / Position / Salary
Name of Supervisor:
Reason for leaving:
D. / Name, Address & Phone Number of Employer:
Date From: / To: / Position / Salary
Name of Supervisor:
Reason for leaving:

If you have ever been employed in law enforcement or security, identify the experience, rank or position held and the amount of time spent in each.

E. / Department/Firm Name:
Position or Rank: / Year From: / To:
F. / Department/Firm Name:
Position or Rank: / Year From: / To:
G. / Department/Firm Name:
Position or Rank: / Year From: / To:
H. / Department/Firm Name:
Position or Rank: / Year From: / To:

VI. Military Service

A. / Have you ever served in the United States Military? / Yes / No
If “YES”, give branch and dates of service:
B. / What type of discharge did you receive?
If not Honorably discharged, give details:

VII. Position Requirements

Listed are the requirements of the Security Officer position. Please check (√) the requirements you are (Yes) or are not (No) able to meet/perform.

Requirement

/ Yes / No
A. / High School Diploma or equivalent
B. / Walk for extended periods of time.
C. / Stand for extended periods of time.
D. / Climb stairs
E. / Run when necessary.
F. / Walk on uneven, wet, snowy or icy terrain
G. / See clearly over extended distances
H. / Climb ladders
I. / Tolerate extremes in weather conditions
J. / Work during any time of day
K. / Possess a good sense of smell
L. / Lift up to 50 lbs with no assistance
M. / Physically remove an adult sized person from one location to another location of safety
N. / Physically restrain combative person(s)
O. / Perform light maintenance, i.e. manipulate screwdrivers and other hand tools
P. / Manipulate small switches and dials
Q. / Distinguish colors (not color-blind)
R. / Good verbal and written skills
S. / Possess valid Illinois Drivers License
If any requirements are checked (√) “No” give details:

VIII – A. Applicant’s Statement

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I hereby acknowledge that in consideration of, and as a condition of my employment, I authorize the Illinois Mathematics and Science Academy and its authorized representatives to investigate all statements contained herein and the references listed above, and to make inquiries of all past or present employers in regard to my employment history, and any pertinent information they may have, personal or otherwise, and I authorize all past or present employers to release such requested information about my employment history to the Illinois Mathematics and Science Academy and its authorized representatives, and I release all parties from all liability for any damage that may result from furnishing same to you.

I understand that neither this application nor any offer of employment represents an employment contract, and I understand and agree that if hired, my employment is for no definite period, and such employment may be terminated at any time without prior notice.

I understand, also, that I am required to abide by all rules and regulations of the Illinois Mathematics and Science Academy.

Name of Applicant (Print):
Signature of Applicant:
Date:

VIII - B. Applicant’s Statement

I do hereby acknowledge that in consideration of, and as a condition of, my employment with the Illinois Mathematics and Science Academy, I authorize the Illinois Mathematics and Science Academy to inquire of the Department of State Police or any other law enforcement agency, any information regarding whether I have been convicted of any criminal or drug offenses, and I authorize that the department of State Police, or any other law enforcement agency, to release such information regarding any such conviction(s) to the Illinois Mathematics and Science Academy.

Name of Applicant (Print):
Signature of Applicant:
Date: