Pages in this section

Employment Application

Northeast Iowa Area Agency on Aging non-discrimination policy
No person shall be discriminated against in employment or provision of services on the basis of race, national or ethnic origin, age, gender, sexual orientation, gender identity, marital status, veteran status, religion, creed, disability or other characteristic protected by law.
NEI3A is an Equal Opportunity Employer

If you need assistance to fill out this application form, or any part of the application, interview or employment process, please email HR@nei3a.org or call 319-874-6846.

All fields marked with an * are required.

Personal Information

First Name *

Middle Name

Last Name *

Home Phone

Mobile Phone

Preferred Phone *

Address *

City *

State *

ZIP *

Position Applied For *

Salary Desired *

Have you ever been employed with us before? Yes
No

For purposes of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States? *

Yes
No
You will be required to provide documentation should you be employed.

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I hereby release from all liability or damage those individuals, corporations or organizations who provide such information.

This application for employment shall be considered active for a period of time not to exceed ninety (90) days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an ‘at will’ nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this ‘at will’ employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. I agree that the company shall not be liable in any respect if my employment is terminated because of falsity of statement, answers or omissions made by me on this application.

I acknowledge that NEI3A is required to conduct a criminal history, child and dependent adult abuse record check for persons employed by Northeast Iowa Area Agency on Aging. A background check will be conducted prior to confirming a conditional job offer.

Northeast Iowa Area Agency on Aging
PO Box 388
Waterloo, IA 50704

This application will be retained for ninety (90) days.

Education

What is the highest level of education have you completed? *

High School or Equivalent
Associates Degree
Field of study:
Bachelors Degree
Field of study:
Masters Degree
Field of study:

Name and address of institution from which highest degree of education was received: *

Specialized training, skills, or abilities

Languages other than English you can speak, read, and/or write

Work Experience

Are you currently employed? * Yes
No

Current Employer (or most recent employer)

Employer Name

Employer Phone

Address

City

State

ZIP

Date of Employment (Start date/end date)

(mm/yyyy)
(mm/yyyy)

Title of Your Position

Name & Title of Your Immediate Supervisor

May we contact this employer? Yes
No

Description of duties, responsibilities and equipment operated

Reason for Leaving

Final Pay

$ Per

Previous Employer 1

Employer Name

Employer Phone

Address

City

State

ZIP

Date of Employment (Start date/end date)

(mm/yyyy)
(mm/yyyy)

Title of Your Position

Name & Title of Your Immediate Supervisor

May we contact this employer? Yes
No

Description of duties, responsibilities and equipment operated

Reason for Leaving

Final Pay

$ Per

Previous Employer 2

Employer Name

Employer Phone

Address

City

State

ZIP

Date of Employment (Start date/end date)

(mm/yyyy)
(mm/yyyy)

Title of Your Position

Name & Title of Your Immediate Supervisor

May we contact this employer? Yes
No

Description of duties, responsibilities and equipment operated

Reason for Leaving

Final Pay

$ Per

Employment Information

On what date would you be available to work? (mm/dd/yyyy)

Hours/week desired

What hours are you available to work?

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Do you have a valid driver's license? Yes
No

If yes, state issued

Can you travel if job requires it? Yes
No

Professional References

Reference 1

Name

Title

Address

Phone Number

Describe Your Relationship to this Reference

Years Known

Reference 2

Name

Title

Address

Phone Number

Describe Your Relationship to this Reference

Years Known

Reference 3

Name

Title

Address

Phone Number

Describe Your Relationship to this Reference

Years Known

Resume and Cover Letter

Upload Resumé and Cover Letter

(Please submit a single PDF or Microsoft Word file)

Affirmative Action Survey (Optional)

Gender Identification Male
Female

Minority Status Identification Hispanic or Latino
White
Black
Native Hawaiian or other Pacific Islander
Asian
American Indian or Alaska Native
Two or More Races

By checking this box and submitting this electronic application, I understand that NEI3A is required to conduct a criminal history, child and dependent adult abuse record check for persons employed by Northeast Iowa Area Agency on Aging. A background check will be conducted prior to confirming a conditional job offer.

Do you agree?* Yes, I agree.

Submit Application

Empowering you to age with confidence.

Notice of Privacy Practices
Nondiscrimination Notice