Do you have relatives working at Progress Industries? Yes        No

If yes, who? Relationship to you?

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

Do you have a car? Yes       No   

Do you have auto insurance? Yes       No    If no, explain

Answering "yes" to the following question does not constitute an automatic bar to employment.  Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever been convicted of a crime in Iowa or any other state, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by a court. Yes       No

(Criminal convictions are not an absolute ban of employment and will be considered only with respect to the specific requirements of the job for which you are applying)

If yes, please provide in detail:

Employment History
Starting with your most recent employer, provide the following information.

We may contact the emplyers listed, unless you indicate those you do not want us to contact
DO NOT CONTACT EMPLOYER # REASON

MILITAY

(Complete this section if you have served in the U.S. Armed Forces)

Describe your duties and special training

Branch of Service:

Period of Active Duty (Month/Year) From: To:

Rank of Discharge:

Date of Final Discharge:

Educational Background
Starting with your most recent school attended, provide the following information.

NOTICE: POST-OFFER/PRE-EMPLOYMENT PHYSICAL EXAM WITH DRUG SCREEN REQUIRED

References
List name and telephone number of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.

WHAT DAYS AND TIMES WOULD YOU BE WILLING TO WORK ON A REGULAR BASIS?
(Write in the earliest time you would be willing to start working, and the latest time you would be willing to stay at work. If there are days of the eek you absolutely cannot work, put an "X" though that day.)

DAY	SUN	MON	TUES	WED	THURS	FRI	SAT
FROM
TO

CHECK HERE IF YOU HAVE NO SPECIFIC PREFERENCE OF WORK TIMES:

PROGRESS INDUSTRIES
CORE VALUES

INTEGRITY – morals, ethics, doing the right thing, truthful, respectful, open, honest communication.

TEAMWORK – accountability, responsibility, same values-alternate methods, P.I. before individual goals.

PASSIONATE ABOUT PEOPLE – treat people fairly, with dignity, balance of life and work, positive, enjoyable work environment, manage from heart, diversity.

SERVICE EXCELLENCE – exceed expectations

SUCCESS DRIVEN – opportunity, innovation, value added service, results driven, fiscal responsibility, open to change, commitment to execution.

PROGRESS INDUSTRIES
VISION
EACH CLIENT SERVED CAN SAY:

• I have a job that I love
• I have friends in the community
• I am proud of my home
• I make a difference

PROGRESS INDUSTRIES
MISSION
“Changing the world for people with disabilities by providing opportunities and skills necessary to fulfill needs and pursue dreams.”

VOLUNTARY IDENTIFICATION INFORMATION
PRE-EMPLOYMENT

Date

Fulll Name

Progress Industries does not discriminate based on age, race, color, religion, sex, gender identity, pregnancy, national origin, citizenship status, disability, sexual orienation, marital status, domestic partner status, or veteran status.

Various agencies of the United States government require employers to collect information on applicants. Information in this section is requested for the purpose of compliance with these requirements.

This information will not affect the decision regarding your application for employment. Providing this information is voluntary, and is not a condion of employment.

Gender:    Male Female  

Ethnic Group African American/Black (Not Hispanic or Latino) American Indian/Alaska Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Caucasian/White (Not Hispanic or Latino Decline to provide Hispanic/Latino Native Hawaiian/Other Pacific Islds (Not Hispanic or Latino) Other Two or More Races (Not Hispanic or Latino) Please select an item.

DEFINITIONS: Federal government regulations define the racial and ethnic classifications as follows:

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of
Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia,
or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of
North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races

*Proof of Citizenship
If you are hired, are you able to provide proof of your employment eligibility in the U.S. within 3 days of your
hire date? (Proof of U.S. Citizenship or Alien work authorization is required by the Immigration Reform and
Control Act of 1986.)]

Yes

No

• MILITARY STATUS:

      Please select one of the following (if applicable)

Vietnam

Era Veteran

Veteran who served in the Active Military, Naval or Air Service in the Southwest Asia Theatre of Operations (8-2-90 to 1-2-92 Persian Gulf)

REFERRAL: (Mark all applicable)

AUTHORIZATION FORM
HUMAN RESOURCES

I understand that Progress Industries ("Company") may obtain a consumer or investigative consumer report in connection with my application for employment. This means that the Company may obtain information on:

• Credit history or credit standing
• Criminal history
• Driving record
• Education record
• Job history
• Job reference information
• Information about your character, reputation or personal characteristic

I understand that the Company may seek this information both at the time of applicaton for a job, and if I am hired, at any time during my employment. By signing below, I am acknowledging that I have read this authorization and will allow the Company to obtain these reports.

I further authorize the Company to share report information among affiliated companies as necessary in connection with hiring, promotion, job reassignment or retention of employment decisions.

I release the Company from any and all liability which may result from information the Company during the hiring process, including information on the application for employment, I may not be hired. If the Company larns after I am hired that I provided false or misleading information during the hiring process or on the job application, I understand that I may face disciplinary action, including termination of my employment.

I understand that nothing in this application for employment or anything said during the interview process creates an employment contract between the Company and me.

*Required:

I understand this process is representative of an electronic signature and is legally binding on me.