MAGIC CITY ENTERPRISES, INC. Cheyenne Professional Rehabilitation Services Employment Application 1780 Westland Road, Cheyenne, WY 82001 (307) 637-8869 *IMPORTANT* Please Read Instructions Stated Below Prior To Completing This Application. Please DO NOT Substitute A Resume In Place Of This Application Or Any Of Its Parts Official Job Title As Stated On Announcement Last Name First Name MI Social Security No. Mailing Address City State/Zip Home Phone Message Phone Drivers License State Type Type Of Employment You Would Accept (please circle all that apply): Full Time Part Time Relief Date Available To Start Work Who Referred You To Magic City? Do You Have Relatives Or Roommates Employed Or Served By Magic City Enterprises? Yes / No If “Yes” Please Specify Their Name and Division __________________________________________________________ If You Have Worked For Magic City In The Past, Please Specify Division And Dates Of Employment. __________________________________________________________________________________________________ ___________________________________________________________________________________ Have You Ever Been Employed Or Attended School Under Any Other Names? Please List. ________________________________________________________________________________________________ Have You Had Any Traffic Violations In The Past 5 Years? Yes / No If Yes, Explain: _______________________________ __________________________________________________________________________________________________ Have You Ever Been Convicted Of A Felony Or Been Legally Incarcerated? Yes / No If “Yes” Please List. __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do You Have A High School Diploma Or Equivalency? Yes / No Please List Location. __________________________________________________________________________________________________ School Name City State Years Completed __________________________________________________________________________________________________ __________________________________________________________________________________________________ College or Vocational School City Dates Hours Degree Earned *WORK HISTORY* Starting With Your Present Or Most Recent Job, List Your Employment History For The Last 10 Years. Employer_____________________________________________________From Mo/Yr____________To: ____________ Address_______________________________________________City_________________ST._________Zip___________ Your Title/Position___________________________________________Last Salary ______________ Per Mo./Yr. _________ Hours Worked Per week________ Supervisor Name/Title___________________________May We Contact This Employer? Yes / No Phone #_____________________ Reason For Leaving: _________________________________________________________________________________ __________________________________________________________________________________________________ Duties_______________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ Employer_____________________________________________________From Mo/Yr____________To: ____________ Address_______________________________________________City_________________ST._________Zip___________ Your Title/Position___________________________________________Last Salary ______________ Per Mo./Yr. _________ Hours Worked Per week________ Supervisor Name/Title___________________________May We Contact This Employer? Yes / No Phone #_____________________ Reason For Leaving: _________________________________________________________________________________ __________________________________________________________________________________________________ Duties_______________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ Employer_____________________________________________________From Mo/Yr____________To: ____________ Address_______________________________________________City_________________ST._________Zip___________ Your Title/Position___________________________________________Last Salary ______________ Per Mo./Yr. _________ Hours Worked Per week________ Supervisor Name/Title___________________________May We Contact This Employer? Yes / No Phone #_____________________ Reason For Leaving: _________________________________________________________________________________ __________________________________________________________________________________________________ Duties_______________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ Please List All Other Job-Related Special Qualifications That Would Pertain To The Position Applied For: __________________________________________________________________________________________________ __________________________________________________________________________________________________ *PERSONAL REFERENCES* Please Provide 3 personal references whom are familiar with your job performance, Please DO NOT use Family and/or Roommates. ______________________________________________________________________________________ Name Telephone Years / Acquaintance ______________________________________________________________________________________ Name Telephone Years / Acquaintance ______________________________________________________________________________________ Name Telephone Years / Acquaintance If you are applying for Direct Care Professional or Job Coach Position, please write a brief paragraph to the following question. How would you teach a person with a developmental disability to wash their clothes? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ *NOTICE* All Applicants Hired Will Be Required To Show Proof That They Are Eligible To Work In The United States, In Compliance With United States Immigration Laws. New Employees Are Required To Pass A Pre-Employment Drug Screening, Provide Education Documentation And Present An Official Copy Of Their Driving Record From The Department Of Motor Vehicles From State In Which License Is Issued. New Employees Will Be Submitted To An FBI/DCI/DFS Background Check With Fingerprints And Are Conditionally Hired Pending The Investigations Satisfactory Results. I Certify That All Information Contained On This Application Is True And Complete To The Best Of My Knowledge And Belief. I Understand That Any Misrepresentation Or Falsifications, May Result In Removal From Employment Consideration Or Dismissal. I Give, Magic City Enterprises, Inc. And Its Authorized Agents Permissions To Verify Any Information Given In Connection With This Application. Signature Of Applicant____________________________________________Date: ______________________ Completion of this section is required to satisfy Federal Equal Opportunity Statistical Reporting and Research Requirements. This section will be detached from the application after processing and will not be made available to hiring agencies. Employees are treated during employment without regard to race, color, religion, creed, gender, national origin, age, disability, martial status or veteran status. We comply with all government regulations, including our Affirmative Action responsibilities where they apply. As a government contract we are required to provide reports containing the following information. Your cooperation is voluntary and very much appreciated. Position Applied For____________________________________________ Referral Source; Advertisment____Friend_____Relative____Walk – In___Other_________________________________ Ethnic Group/Race; Caucasion _____African American____Hispanic_____Asian_____American Indian____Other_____________ Veteran Status; Not Applicable____Vietnam Era___Desert Storm Veteran___Enduring Freedon Veteran_____Disabled Veteran____ Gender; Male____Female____