IMPACT Wellness Center · Employment Application

Contact Information

Name

*

First Name

Last Name

Email

Verify Email

Daytime Phone

Cell Phone

Preferred Form of Contact

*

Daytime Phone

Cell Phone

Email

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

State driver's license was issued:

Driver's License #

Are you a U.S. citizen?

Yes

No

Can you legally work in the U.S.?

Yes

No

What languages do you speak fluently?

Please check all that apply

English

Spanish

French

German

Chinese

Japanese

Other

Other languages you speak fluently that were not listed:

Position Requirements

What type of employment are you seeking?

Full-time

Part-time

What position are you applying for?

Administration

Kamp Counselor

Tutor

Skills Trainer

Desired Compensation:

*

Hourly

Annual Salary

Please list your desired compensation amount:

*

What days are you available to work?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Applicant Background

Have you ever been convicted of a crime?

Yes

No

Answering yes to the question above does not automatically disqualify you for consideration for this position.

What type of crime(s) have you been convicted of:

Felony

Gross Misdemeanor

Misdemeanor

Please explain your conviction

include conviction month/year in all responses

Work History

Have you ever worked for I.M.P.A.C.T, INC.

Yes

No

When and what position:

Purpose for leaving:

Resigned

Terminated

Have any immediate family members ever worked for I.M.P.A.C.T, INC?

Yes

No

When and what position:

Please list your last 3 employers

starting with the most current

Organization/Employer #1

Supervisor Name #1

First Name

Last Name

Address #1

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Still employed?

Yes

No

Hire Date

(mm/dd/yyyy)

Termination Date

(mm/dd/yyyy)

Responsibilities / Job duties #1

Reason for leaving:

Organization/Employer #2

Supervisor Name #2

First Name

Last Name

Address #2

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Hire Date

(mm/dd/yyyy)

Termination Date

(mm/dd/yyyy)

Responsibilities / Job duties #2

Reason for leaving:

Organization/Employer #3

Supervisor Name #3

First Name

Last Name

Address #3

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Hire Date

(mm/dd/yyyy)

Termination Date

(mm/dd/yyyy)

Responsibilities / Job duties #3

Educational Background

Please check all that apply

High School / GED

Associate's Degree

Bachelor's Degree

Master's Degree

JD Degree

Doctorate Degree

Date of Graduation (High School / GED)

(mm/dd/yyyy)

Associate's Degree of Study

Please list major/field

Date of Graduation (Associate's)

(mm/dd/yyyy)

Bachelor's Degree of Study

Please list major/field

Date of Graduation (Bachelor)

(mm/dd/yyyy)

Master's Degree of Study

Please list major/field

Date of Graduation (Master)

(mm/dd/yyyy)

JD Degree of Study

Please list major/field

Date of Graduation (JD)

(mm/dd/yyyy)

Doctorate Degree of Study

Please list major/field

Date of Graduation (Doctoral)

(mm/dd/yyyy)

Other applicable training / education / experience

Professional licenses or certifications:

References

Please provide at least 1 personal reference and 2 professional references

Personal Reference

First Name

Last Name

Relationship to applicant

Email

Verify Email

Phone

Professional Reference #1

Professional Reference

First Name

Last Name

Organization/Employer

Title

Email

Verify Email

Phone

Professional Reference #2

Professional Reference

First Name

Last Name

Organization/Employer

Title

Email

Verify Email

Phone

Files to be uploaded

Upload your resume

*

Upload your cover letter

*

Upload Unofficial College Transcripts

Equal Opportunity / Affirmative Action / Civil Rights Policies and Procedures

It is the policy of I.M.P.A.C.T, INC to seek, emply, assign and promote the best qualified personnel in all of its operations, and to provide an equal opportunity for the advancement of employees, including trianing, upgrading and promotion, all in a manner which will not discriminate against any person on the basis of age, race, ethnicity, gender, creed, color, national origin, sexual orientatin, religion, marital status, or physical and / or mental disability. Applications for employment will be accorded equal treatment with respect to all terms, conditions, and privileges of employment, including recruitment, selection, placement, training and opportunities for advancement. In addition I.M.P.A.C.T, INC recognizes the need to reach out and assist individuals who might not otherwise be reached by our organization for employment opportunities.

It is not the policy of I.M.P.A.C.T, INC to promote preferential treatment, reverse discrimination, or quotas, but rather to implement remedial affirmation action to correct any staffing pattern which shows and underutilization of persons listed above and to prevent further employment discrimination of such persons. This policy applies to all levels of employment, and shall be considered an integral part of the personnel policy of the organization.

It is the intent of I.M.P.A.C.T, INC to comply with the spirit and the letter of state and federal constitution mandate, civil rights, regulations of various departments and executive orders of the Governor of the State of Nevada and the President of the United States of America.

Acknowledgement

*

By submitting this form you acknowledge that as part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.

I Agree

Please Type Your Initals

*

This will be your application signature