Name:

Street Address:
City, State, ZIP Code:

Home telephone number:
Work telephone number:
May we contact you at work? Yes | No
Mobile telephone number:
Email address:

Name of program for which you are applying:

Minimum salary expectation:

Date you are available:

Are you legally eligible for employment in the United States? Yes | No

Are you related to a Phalanx Family Services staff member? Yes | No

If you answered "Yes," please provide the name of the employee and your relationship:

Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?
Yes | No

If you answered "Yes," please explain:

EDUCATION and TRAINING

Last high school attended:

Did you graduate? Yes | No

If you answered "No," do you have a high school equivalency (GED)? Yes | No
If "Yes," State GED awarded:

SPECIALIZED SKILLS: (Include business equipment, computer hardware and software, mechanical/technical, foreign language, sign language or public service training and skills. Also include any professional certifications or licenses held.)

REFERRED BY:

WORK EXPERIENCE
Provide a complete record of your work history over the past ten years (longer if you desire) including part-time work, temporary or seasonal, military service, volunteer work and internships. List all experience in order, beginning with your present or most recent position. Use a supplemental sheet if additional space is needed. E-mail, fax or mail the supplemental list to the Human Resources Department.

Employer:
Employer's complete address:

Employer telephone number:
Nature of business:
Position held:
Name of supervisor:
Reason for leaving:

Employer:
Employer's complete address:

Employer telephone number:
Nature of business:
Position held:
Name of supervisor:
Reason for leaving:

Employer:
Employer's complete address:

Employer telephone number:
Nature of business:
Position held:
Name of supervisor:
Reason for leaving:

Employer:
Employer's complete address:

Employer telephone number:
Nature of business:
Position held:
Name of supervisor:
Reason for leaving:

HOURS AVAILABLE (part-time applicants only)

Please list hours you are available to work:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

PREFERRED LOCATIONS (part-time applicants only)

REFERENCES

List business or professional references only. Please do not list relatives.

May we contact your current employer? Yes | No

RESUME

Please do not submit a Resume with this application.  This application is for our programs only!   If you would like to apply for employment with Phalanx, please click "Submit Resume" for information on obtaining a position with our organization.  If you are experiencing difficulty submitting this form, please contact our office at 773-261-5100, or E-mail hbailey@phalanxgrpservices.org. 

"UNDER ILLINOIS LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. ANY EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100."

I hereby acknowledge that I have read and understand the polygraph notice written above:
Date of acknowledgement:

I hereby certify that any and all statements made on this application are true, complete and correct to the best of my knowledge and are made in good faith and I authorize Phalanx Family Services to investigate the statements made on this application. I understand that any misrepresentations or false statements made on this application could render it void and, if employed, could be cause for not being allowed to register for programs through Phalanx.

A signature is not required to submit your application.  You will be contacted after we receive your application.

Phalanx Family Services treat all applicants equally and without regard to their race, color, religion, sex, national origin, disability status as a disabled veteran or veteran of the Vietnam Era. This policy is applicable to all aspects of training and promotions.

MAKE SURE YOU HAVE ANSWERED ALL THE QUESTIONS ON THIS FORM!
FAILURE TO COMPLETE MAY RESULT IN REJECTION OF APPLICATION.

Submit this form by using the button below.
If you encounter an error, please use the "Back" command in your browser to return to this web page. You may print-out this form (you must select the "LANDSCAPE" print mode) and mail or fax a copy to:

Phalanx Family Services
Human Resources
4628 W. Washington
Chicago, IL  60644
Fax: 773-261-5100