Online Application – Youth Service Bureau

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Online Application

The Youth Service Bureau of Jay County, Inc. considers applications for all positions without regard to race, religious creed, color, sex, age, national origin, marital or veteran status, or any other legally protected status.

Employment with The Youth Service Bureau of Jay County Inc. (YSB) is a voluntary one and is subject to termination by you or the YSB at will, with or without cause, and with or without notice, at any time., Portland, Indiana 47371.

Online Application

Position you are applying for: *

Date

Name *

First

Middle

Last

Current Address - Street Name & Number

City

State

Zip Code

How long have you been at your current address?

Home Phone (E.g. 222-222-2222) *

Business Phone Number (E.g. 222-222-2222)

Social Security Number (E.g 222-22-2222) *

Email *

Are you at least 21 years of age? *

Yes
No

Are you currently employed?

Yes
No

May we contact your current employer?

Yes
No

If no, please state the reason below:

Will you work overtime if asked?

Yes
No

Are you legally eligible to work in the United States? *

Yes
No

If the answer to the previous question is no, do you have a work permit?

Yes
No

When will you be able to start working?

Are you able to work:

Full Time
Part Time

Have you ever been convicted of a felony? *

Yes
No

If yes, please explain fully:

Are you physically or otherwise unable to perform the duties for the job in which you are applying?

Yes
No

Do you serve in the U.S Armed Forces?

Yes
No

If yes, which branch?

Do you currently have a valid driver's license? *

Yes
No

What is your driver's license number? *

Have You Ever Been Discharged, Asked to Resign, Furlough, or Put in Inactive Status for Cause, or Subjected to Disciplinary Action in any Position? *

Yes
No

If yes, please explain: *

Have You Ever Been Arrested Detained or Involved in any Court Action? *

Yes
No

If yes, please explain: *

How did you hear of this position?

Website
School Posting
News Posting

Signature *

I Certify, that there are No Misrepresentations, Omissions, or Falsifications in the Foregoing Statements and Answers, and that the Entries Made by Me Above are True, Complete, and Correct to the Best of My Knowledge and are Made in Good Faith. I Further Agree and Consent in Advance to Being Summarily Discharged Without Cause or Hearing if any of the Above Information Contains any Misrepresentation or Falsification or if any Material Information has been Omitted.

High School - Name and Location *

Years Completed *

Did you graduate? *

Yes
No

Diploma/Degree/ *

Trade/Technical/Undergraduate College/Undergraduate Name and Location *

Years Completed *

Did you graduate? *

Yes
No

Diploma/Degree *

Describe any training or special skills and/or extracurricular activities:

Any additional information about yourself you may find important to mention:

List Professional and/or civic activities and offices held. You may exclude memberships which would reveal sex, race, national origin, age, and any other legally protected status

Reference 1 - Name and Address *

Telephone Number *

Years Known *

Reference 2 - Name and Address *

Telephone Number *

Years Known *

Reference 3 - Name and Address *

Telephone Number

Years Known

Reference 4 - Name and Address

Telephone Number

Years Known

Reference 5 - Name and Address

Telephone Number

Years Known

Work Experience - Four Employers, Starting with Your Present, or Last Job, Name and Address *

Date Started - Date Ended *

Telephone Number *

Salary Rate Starting/Final Salary Rate *

Job Title *

Job Duties *

Supervisor *

Reason for leaving *

Work Experience - 2nd Employer Name and Address *

Date Started - Date Ended *

Telephone Number *

Salary Rate Starting/Final Salary Rate *

Job Title *

Job Duties *

Supervisor *

Reason for leaving *

Work Experience - 3rd Employer Name and Address

Date Started - Date Ended

Telephone Number

Salary Rate Starting/Final Salary Rate

Job Title

Job Duties

Supervisor

Reason for leaving

Work Experience - 4th Employer Name and Address

Date Started - Date Ended

Telephone Number

Salary Rate Starting/Final Salary Rate

Job Title

Job Duties

Supervisor

Reason for leaving

I give my permission and authorize for the following background checks to be completed, with the information being released to the Youth Service Bureau of Jay County, Inc. Federal Fingerprint Check – Including Limited Criminal History Check Sex and Violent Offender Registry Check/Child Protective Services – Department of Child Services Local Criminal History Check – County Sheriff’s Department (Cost of fingerprint check and limited criminal history check will be at applicant’s expense. After six months of active employment, employee will be reimbursed for cost. Must have receipt for reimbursement) *

First

Last

Print Name *

First

Last

Date

PERSONNEL FILE

The following items must be in a new employees personnel file
before they will be permitted to start training:

Copy of Diploma for the highest degree obtained
Official transcripts of the highest degree obtained
Declaration page of auto insurance indicating minimum personal
liability coverage of 100,000/300,000
Copy of driver’s license
Copy of social security card
Employee physical examination

Company

Contact Us

Youth Service Bureau
603 West Arch Street
Portland, Indiana 47371

Email: ysbjc@ysbjc.com

Telephone: (260) 726-8520
Fax: (260) 726-8535

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