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Deaf Independent Living Assocation
is a Equal Opportunity Employer

PERSONAL INFORMATION:

Position Applying for*
First Name*
Last Name*
Middle Initial
Street Address
Address (cont.)
City
State
Zip Code
Home Phone
E-mail*
Have you ever applied to DILA before:
If yes, what position did you apply for and when?
Have you ever worked for DILA before:
If yes, what position did you hold and when was your last day of employment with DILA?

EDUCATION:

High School
Course of Study
Highest Level/Degree

College
Course of Study
Highest Level/Degree

Other/Technical
Course of Study
Highest Level/Degree

Special skills, training, etc.?

EMPLOYMENT HISTORY
(List below all present and past employment for the last ten years beginning with the most recent)

1. Company Name
Work Phone
Street Address
Address (cont.)
City
State
Zip Code
Position Held
Dates From/To
Duties
Reason for Leaving
Rate of Pay at Departure
Name of Immediate Supervisor:
May we contact your employer?

2. Company Name
Work Phone
Street Address
Address (cont.)
City
State
Zip Code
Position Held
Dates From/To
Duties
Reason for Leaving
Rate of Pay at Departure
Name of Immediate Supervisor:
May we contact your employer?

3. Company Name
Work Phone
Street Address
Address (cont.)
City
State
Zip Code
Position Held
Dates From/To
Duties
Reason for Leaving
Rate of Pay at Departure
Name of Immediate Supervisor:
May we contact your employer?

REFERENCES (List business or professional persons known, but not related, to you for at least three years)

1. Reference Name
Position
Company/School
Street Address
Address (cont.)
City
State
Zip Code
Phone

2. Reference Name
Position
Company/School
Street Address
Address (cont.)
City
State
Zip Code
Phone

3. Reference Name
Position
Company/School
Street Address
Address (cont.)
City
State
Zip Code
Phone

CONVICTION RECORD:

Have you ever been convicted of a felony or crime of violence, or pleaded no contest in a felony, or been convicted of a misdemeanor resulting in imprisonment or a fine over $500 during the last ten years? (Conviction will not necessarily disqualify applicant but failure to disclose this information could result in immediate termination.)

Yes No If 'Yes', please explain:
MILITARY SERVICE RECORD:
Were you in the U.S. Armed Forces? Yes No
If 'Yes', what Branch?
Dates of Duty (To & From)?
Type of discharge?
U.S. CITIZENSHIP:

U.S. CITIZENSHIP: Are you legally eligible for employment in the United States? Yes No
If 'Yes', Alien Registration Number:

The above information is true and complete to the best of my knowledge. Should I be employed by the Agency, any misrepresentation or false statement contained herein may be considered cause for possible dismissal. The Agency has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior employment, personal history or credit standing and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice to me. I reserve the right to know the names and addresses of any investigative agencies used in order that I may learn the information contained in any reports furnished to the Agency.

I understand that this application does not constitute an employment contract of any kind. Should I be employed by the Agency, I may resign such employment at any time at my discretion with or without prior notice and the Agency may terminate my employment at any time at their discretion, with or without cause and with or without prior notice.

I understand that it is DILA’s policy to run background and MVA checks on all applicants.

Mail, email or fax a separate Letter of Interest, indicating which position you are applying for, along with your resume.

Today's Date: -- mm/dd/yy

By clicking the 'Submit Form' button below, I attest that the above information is true and complete to the best of my knowledge.

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