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2. EMPLOYMENT APPLICATION
   Read this application carefully, there is a final portion that requires a preemptive step in order to complete this application. All links for downloads and uploads are within.
3. RELEASE AND WAIVER LIABILITY PAGE
   RELEASE AND WAIVER LIABILITY.PDF

   Download, print, fill-out and sign this page as part of this application. You will need to scan it then upload it as part of the final step at the end of this application.
5. Please fill out the form below for the position.
7. * Indicates a required field
9. Exact title of the position you are applying for:*
11. Provide contact information:
13. Last Name:*
14. Middle Name:
    (Initial)
15. First Name:*
17. Address Line 1:*
19. Address Line 2:
21. City:*
22. State:*
23. Zip:*
25. Home Phone:
26. Cell Phone:*
27. Fax Number:
28. Email Address:*
32. Driver's Lic. No.:*
33. State*
34. Expiration Date*
35. Lic. Class*
37. List all relavent Education, Training and Certifications
39. Highest Grade Completed*
40. Graduate?*
    -- Select One --YesNoGED
41. School Name and Address*
43. College, Trade or Business School
44. City and State of the Institution
45. Subject / Major of Study
46. Units / Dgree or Cert Acquired?
48. Certificate(s) or License(s) of Professional or Vocational Competence(s)
    (Please upload below)
49. Membership in Professional or Technical Associations:
    (Must be active member)
51. Upload Degree(s), License(s) or Certificate(s)
    You may download separately with resume below.
52. Other Special Training or Skills:
    (Language, office equipment, machine operation, etc…)
56. Are you related to any Heartland Communications Facility Authority employee?*

    1. Yes

    1. No
57. Have you ever been employed by Heartland Communications Facility Authority?*

    1. Yes

    1. No
59. If yes to any of the above, provide additional information here.
    Please note this information will in no way disqualify you.
63. Military Information*

    1. Not a Veteran
    2. Veteran

    1. Disabled Veteran
    2. Spouse of Disabled Veteran
65. If you meet the criteria for veteran preference points, please attach photocopy of DD214 or appropriate documents.
66. Upload proper file
    (ie...DD214)
68. Employment - List applicable previous experience(s):
70. List all jobs you have held in the last ten years. (Resumes may not be substituted) Include active military service, if any. PUT YOUR PRESENT OR MOST RECENT JOB FIRST. Provide all information relevant to the position for which you are applying. By being complete, you may improve your chances for employment. If you need more space, you may upload additional sheet(s) at the end of this section.
72. From:*
73. To:*
74. Position Title*
76. Employer Name & Address*
77. Supervisor
    Please provide immediate supervisor's name, title and phone number.
79. Duties:
    Describe your duties and/or responsibilities as they relate to this position.
81. Reason for Leaving*
    Type in "Present" if present job
82. Full or Part Time*

    1. Full-Time
    2. Part-Time
86. From:*
87. To:*
88. Position Title*
90. Employer Name & Address*
91. Supervisor
    Please provide immediate supervisor's name, title and phone number.
93. Duties:
    Describe your duties and/or responsibilities as they relate to this position.
95. Reason for Leaving*
96. Full or Part Time*

    1. Full-Time
    2. Part-Time
100. From:*
101. To:*
102. Position Title*
104. Employer Name & Address*
105. Supervisor
     Please provide immediate supervisor's name, title and phone number.
107. Duties:
     Describe your duties and/or responsibilities as they relate to this position.
109. Reason for Leaving*
110. Full or Part Time*

     1. Full-Time
     2. Part-Time
114. From:*
115. To:*
116. Position Title*
118. Employer Name & Address*
119. Supervisor
     Please provide immediate supervisor's name, title and phone number.
121. Duties:
     Describe your duties and/or responsibilities as they relate to this position.
123. Reason for Leaving*
124. Full or Part Time*

     1. Full-Time
     2. Part-Time
126. Upload resume and/or additional employment materials here
130. May we contact your present employer?

     1. YES
     2. NO
131. If "NO" then please explain:
135. NOTE:
     After employment, you must submit proof of your legal right to work in the United States of America.
137. AFFIDAVIT - Please Read Carefully
     I DECLARE UNDER PENALTY OF PERJURY THAT ALL THE ANSWERS AND STATEMENTS IN THIS APPLICATION ARE TRUE AND COMPLETED TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT UNTRUTHFULNESS OR MISLEADING ANSWERS ARE CAUSE FOR REJECTION OF THIS APPLICATION, REMOVAL FROM AN ELIGIBLE LIST OR DISMISSAL FROM HCFA EMPLOYMENT.
     
     I UNDERSTAND THAT A PHYSICAL EXAMINATION PRIOR TO EMPLOYMENT, AN ALCOHOL AND DRUG SCREEN, BACKGROUND INVESTIGATION, CREDIT CHECK, AND/OR D.M.V. CHECK MAY BE REQUIRED. I UNDERSTAND THAT THE RESULTS OF ANY OF THE FOREGOING MAY BE GROUNDS FOR DISQUALIFICATION.
139. Signature*
     By inserting your full name, you hereby indicate that you have read and agree to the aforementioned affidavit.
140. Today's Date and Time:
     Today's Date and Time:

     Today's Date and Time:
142. Availability:
144. Can you work in a flexible schedule?*

     1. Yes
     2. No
145. Fulltime/Part-time:*
     -- Select One --Full-TimePart-TimeBoth
147. In addition to this online application,
     how have you applied?*

     (Check all that apply)

     1. Email
     2. In Person
     3. Facsimile

     1. Snail Mail
     2. Online Only
148. Date of availability:*
150. CONFIDENTIAL
     The information you provide in this section of this form will be detached from the application prior to the examination process.
152. NAME:*
153. SOCIAL SECURITY NUMBER:*
155. POSITION:
156. EXAM NUMBER
160. DISABILITY:

     1. YES
     2. NO
161. If you have a disability, please describe:
     NOTE: If you have a disability which may require “Reasonable Accommodations” in the testing process, you need to obtain and complete a “Reasonable Accommodation Request Form” from Heartland Communications at the time of application.
163. How did you hear about this position?

     1. Newspaper
     2. Job Bulletin

     1. Heartland Communications Employee

     1. Recorded Job Line

     1. Other
167. HEARTLAND COMMUNICATIONS FACILITY AUTHORITY AFFIRMATIVE ACTION RESEARCH PROJECT
     Heartland Communications Facility Authority requests that applicants voluntarily provide the following information. This information will not be included with your application, but will be available for research and evaluation purposes only. This information will have absolutely no effect on our selection process. Thank you for your cooperation.
169. Age:
170. Sex:

     1. Male
     2. Female
171. I consider myself a member of the following ethnic group:

     1. Native American
     2. African American
     3. White
     4. Hispanic
     5. Asian / Filipino / Pacific Islander

     (check only one)
175. Signature of Applicant:*
     By inserting your full name, you hereby indicate that you have read, acknowledged and completed the required portion of this section; And you have acknowledged, whether you completed or not, the voluntary information portion in this confidential section of this application.
176. Today's Date and Time:*
     Today's Date and Time:

     Today's Date and Time:
180. Additional Required Step Necessary for the completion of this application.
     An additional document titled, "RELEASE AND WAIVER OF LIABILITY", is required as part of this application. Please download the page marked so, print and sign it then scan and upload it as part of this application.
182. RELEASE AND WAIVER LIABILITY DOWNLOAD PAGE
     RELEASE AND WAIVER LIABILITY.PDF
183. RELEASE AND WAIVER LIABILITY PAGE - completed, signed, scanned and upload here*
Leave This Blank:


185. 1. Receive an email copy of this form.
186. Email address

     This field is not part of the form submission.

187. Submit

* indicates a required field