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We consider applicants for all positions without regard to race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, marital or veteran status, or any other legally protected status.

How did you learn about Region V Services or this opening?
Have you ever been employed with us before?
Do any of your friends/relatives other than spouse work for Region V Services?
Are you currently employed?
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Proof of citizenship or immigration status will be required upon employment.

Have you ever been convicted* of a violation of law other than a minor traffic violation?

*Note: A conviction is not an automatic bar to employment; each case is considered on its own merits in relation to the position applied for

Do you have a car to get to work and/or perform required work duties?
Do you have any physical condition which may limit your ability to perform the job you are applying for?
What is your availability to work? (Please check all that apply):



List below all present and past employment. Begin with your most recent employment.


PERSONAL REFERENCES Not former employers or relatives.


I understand, accept and agree that:

I hereby certify that the facts set forth in my application for employment are true and complete to the best of my knowledge. Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of employment, or if employed, termination of employment.

As a condition of my employment, I will submit to fingerprint and Nebraska Central Registry criminal history inquiries.

My employment may be terminated by Region V Services at any time without liability for wages or salary except such as may have been earned at the date of such termination. If requested by the management at any time, I agree to submit to search of my person or any locker that may be assigned to me, and I hereby waive all claims of damages on account of such examination.

I may be required to take a physical examination at any time at Region V Service’s expense to determine if I am capable of performing the job I am applying for, or may be subsequently hired for. I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of the job prior to employment, or in the future during my employment with Region V Services.

As a condition of my continuing employment, I may be required to work any of the following: overtime, shift work, a rotating work schedule, or a work schedule other than Monday through Friday. Although Region V Services makes every effort to accommodate individual preferences, business needs may at times make these conditions mandatory.

This is an Application for Employment, and no employment contract is being offered. If I am employed, such employment is for an indefinite period of time, and that Region V Services can change wages, benefits and conditions at any time.

I authorize Region V Services to obtain criminal history record information checks from any law enforcement, including the Federal Bureau of Investigation. If I so choose, I may obtain a copy of the results directly from Region V Services.


I have read and understand the above.