2821 South Russell Street, Missoula, Montana 59801-7913 (406) 721-2930 FAX (406) 721-8744 TDD (800) 253-4091

The employment policy of Opportunity Resources, Inc. is to provide equal employment opportunity for all qualified

employees and applicants without regard to race, color, sex, sexual orientation, gender identity, religion, national origin,

disability, veteran status, or other legally protected status and to ensure affirmative action is taken in fulfillment of this

policy.

APPLICATIONS THAT ARE NOT FILLED OUT COMPLETELY CANNOT BE CONSIDERED.

IF A QUESTION DOES NOT PERTAIN TO YOU, WRITE IN THE LETTERS (NA).

NAME: EMAIL:

Last First Middle

ADDRESS:

Street and/or mailing City State Zip

PHONE NUMBER(S):

Home Cell Work/Message

Position(s) Applying for:

Date Available for Employment: Wage/Salary Requirement:

Planned Length of Employment at ORI: Full-time Part-time Temporary

Do you have any relatives currently working for ORI? No Yes, who?

EDUCATION AND TRAINING

Type Name & Location Years Completed Major Degree or

Diploma Received

High School

College

College

Other

Other

PROFESSIONAL LICENSES, REGISTRATIONS &/OR CERTIFICATIONS

Type State

Issued Number

Expiration

Date Type

State

Issued Number

Expiration

Date

CPR: Other:

First Aid: Other:

MANDT: Other:

Medication

Certification

Driver’s

License:

ADDITIONAL SKILLS

Computer Skills (software used & skill level – beginner, intermediate, advanced):

Other Skills (i.e., office equipment, tools/machines, foreign/sign language, etc.):

EMPLOYMENT HISTORY (List present or most recent job related experience first, include fulltime, part-time and

volunteer work.) Describe your specific duties, responsibilities and accomplishments in this job, including a review of

any supervisory responsibilities and special skills required.

DATES EMPLOYED SALARY HOW LONG HOURS

PER WEEK POSITION TITLE

From: To: Start: End:

Employer: Address:

Name/Title of Supervisor: Phone:

Reason(s) for Leaving:

Why would you NOT return to this position if offered:

Why WOULD you return to this position if offered:

Describe Your Responsibilities:

DATES EMPLOYED SALARY HOW LONG HOURS

PER WEEK POSITION TITLE

From: To: Start: End:

Employer: Address:

Name/Title of Supervisor: Phone:

Reason(s) for Leaving:

Why would you NOT return to this position if offered:

Why WOULD you return to this position if offered:

Describe Your Responsibilities:

DATES EMPLOYED SALARY HOW LONG HOURS

PER WEEK POSITION TITLE

From: To: Start: End:

Employer: Address:

Name/Title of Supervisor: Phone:

Reason(s) for Leaving:

Why would you NOT return to this position if offered:

Why WOULD you return to this position if offered:

Describe Your Responsibilities:

EMPLOYMENT HISTORY (continued)

DATES EMPLOYED SALARY HOW LONG HOURS

PER WEEK POSITION TITLE

From: To: Start: End:

Employer: Address:

Name/Title of Supervisor: Phone:

Reason(s) for Leaving:

Why would you NOT return to this position if offered:

Why WOULD you return to this position if offered:

Describe Your Responsibilities:

DATES EMPLOYED SALARY HOW LONG HOURS

PER WEEK POSITION TITLE

From: To: Start: End:

Employer: Address:

Name/Title of Supervisor: Phone:

Reason(s) for Leaving:

Why would you NOT return to this position if offered:

Why WOULD you return to this position if offered:

Describe Your Responsibilities:

SUPPLEMENTAL BACKGROUND INFORMATION (Please explain any “yes” answer in space provided below.) 1. Have you ever been convicted for neglect or abuse, sexual abuse or other acts of violence? Yes No

2. Have you ever been convicted for violating any other law or ordinance (excluding minor traffic violations)? Yes No 3. Are you currently being investigated for neglect, abuse of any violation of any law? Yes No 4. Have you ever been terminated from any job for any reason other than a layoff? Yes No 5. Is there any reason why you cannot perform the essential functions of the job you are applying for? Yes No

Please note, conviction does not automatically exclude you from consideration for employment.

Question # Date Explanation

ADDITIONAL INFORMATION: Please provide any additional information that may more fully describe your

qualifications and capabilities, especially those related to the particular position for which you are applying. This space

may be used to continue description of your education and experience.

PROFESSIONAL REFERENCES

(please do not list employers or relatives)

Name Address Occupation/Title Phone

I voluntarily authorize Opportunity Resources, Inc., the right to complete a background check which will include

contacting my current and former employers, law enforcement agencies, &/or other personal and professional references.

I DO want to be notified before you contact my present employer for a reference check.

I waive any claim against a previous employer or personal reference for any statement made by reference in support or

opposition to my prospective employment and understand that Opportunity Resources, Inc., will suffer no liability as the

result of such inquires.

I understand all offers of employment are contingent on verification of references, driving history, criminal history, &/or

credentials. I hereby guarantee the correctness of the above statements. The making of false or misleading statements or

any material omission will be sufficient cause for denying me consideration for employment or dismissal from

employment.

I also understand that if hired, my employment shall not be construed as contractual between Opportunity Resources, Inc.,

and me for any fixed or perpetual term

SIGNATURE OF APPLICANT DATE

RECRUITMENT FORM

Name: Phone (H):

Email: Phone (C):

Address: (Street) (City) (State) (Zip)

Where did you hear about this job opening? Friend told me ORI Reader Board

Missoulian Craigslist Job Job Service I work at ORI

Independent Kaimin Other

Current member of Opportunity Recruited me, their name:

Date of most recent application: (If you do not know, it is YOUR responsibility to find out from Human Resource)

Would you be interested in a Direct Support Position available with ORI? NO

(FROM APPLICATION PACKET COVER LETTER)

Position Applying for:

Hours/Description of Position Applying for:

Position closing, date/time:

You MUST complete this form for EACH POSITION you want to be considered for and return it to the Front Office before the closing date/time of the position.

FOR OFFICIAL USE ONLY

Opening Date: Hiring Manager:

Results: Hired: Yes No

SUB: DSP:

YES

Voluntary Pre-Offer Self-ID For use with plans effective on/after March 24, 2014

Page 1 of 1

PRE-OFFER PROTECTED VETERAN

SELF-IDENTIFICATION FORM

This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act

of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires

Government contractors to take affirmative action to employ and advance in employment: (1) disabled

veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed

Forces service medal veterans. These classifications are defined as follows:

A “disabled veteran” is one of the following:

o a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or

who but for the receipt of military retired pay would be entitled to compensation) under laws

administered by the Secretary of Veterans Affairs; or

o a person who was discharged or released from active duty because of a service-connected

disability.

A “recently separated veteran” means any veteran during the three-year period beginning on the date

of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air

service.

An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in

the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a

campaign badge has been authorized under the laws administered by the Department of Defense.

An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the

U.S. military, ground, naval or air service, participated in a United States military operation for which

an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and

Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in

the uniformed service, you may be entitled to be reemployed by your employer in the position you would have

obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S.

Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse

treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era

Veterans’ Readjustment Assistance Act of 1974, as amended.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by

checking the appropriate box below.

As a Government contractor subject to VEVRAA, we request this information in order to measure the

effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED

VETERAN LISTED ABOVE

I AM NOT A PROTECTED VETERAN

I CHOOSE NOT TO SELF-IDENTIFY

_______________________________ _______________ ________________________________

Signature Date Print Name

PLEASE RETURN THIS FORM TO YOUR HUMAN RESOURCES REPRESENTATIVE

__________________________ __________________

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017 Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to

qualified people with disabilities i To help us measure how well we are doing, we are asking you to tell us if you

have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will

choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used

against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may

become disabled at any time, we are required to ask all of our employees to update their information every five

years. You may voluntarily self-identify as having a disability on this form without fear of any punishment

because you did not identify as having a disability earlier.

.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that

substantially limits a major life activity, or if you have a history or record of such an impairment or medical

condition.

Disabilities include, but are not limited to:

Blindness

Deafness Cancer Diabetes

Epilepsy

Autism

Cerebral palsy

HIV/AIDS

Schizophrenia

Muscular dystrophy

Bipolar disorder

Major depression

Multiple sclerosis (MS)

Missing limbs or partially missing limbs

Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair

Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

☐ YES, I HAVE A DISABILITY (or previously had a disability)

☐ NO, I DON’T HAVE A DISABILITY

☐ I DON’T WISH TO ANSWER

Your Name Today’s Date

i

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005

Expires 1/31/2017 Page 2 of 2

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.

Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples

of reasonable accommodation include making a change to the application process or work procedures,

providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal

employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract

Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required

to respond to a collection of information unless such collection displays a valid OMB control number. This

survey should take about 5 minutes to complete.

EEO-1 Self-Identification Form

OPPORTUNITY RESOURCES, INC. is subject to certain governmental recordkeeping and reporting requirements

for the administration of civil rights laws and regulations. In order to comply with these laws, OPPORTUNITY

RESOURCES, INC invites applicants to voluntarily self-identify their gender, race and ethnicity. Submission of

this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information

will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive

orders, and regulations, including those that require the information to be summarized and reported to the federal

government for civil rights enforcement. When reported, data will not identify any specific individual.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application

for Employment.

(PLEASE PRINT) Date: __________________________

Position(s) Applied For: ________________________________________________________________

Location of Position: __________________________________________________________________

Referral Source(s): State Employment Agency Friend Relative

Walk-In Company Website

Other _________________________________________________________

Name: ______________________________________________ Phone _____-______-__________

LAST FIRST MIDDLE

Address: ____________________________________________________________________________ NUMBER STREET CITY STATE ZIP CODE

1. Gender Male Female

2. Ethnicity Are you Hispanic or Latino? A person of Cuban, Mexican, Puerto Rican, Central or South

American, or other Spanish culture or origin, regardless of race.

Yes, I am Hispanic or Latino. No, I am not Hispanic or Latino.

3. Race IMPORTANT – If you checked “No, I am not Hispanic or Latino” on #2, then check one or more of the following, as they apply:

White A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Black or African American A person having origins in any of the Black racial groups of Africa.

American Indian/Alaskan Native A person having origins in any of the original peoples of North America and South America (including

Central America), and who maintains tribal affiliation or community attachment.

Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian

subcontinent.

Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

DEPARTMENT OF

PUBLIC HEALTH AND HUMAN SERVICES

STATE OF MONTANA

PLEASE COMPLETE BOTH SIDES OF THIS FORM

DPHHS-QAD/CRL-18 (Revision 5-10)

- RELEASE OF INFORMATION - For Adult and Youth Care Facility Providers Criminal / Protective Service / Motor Vehicle

Background Checks

PERSONAL INFORMATION

Section A – Current Information Phone # ________________________ Legal Name: ______________________________________________________________________________________

(First) (Middle) (Maiden) (Last)

Aliases/Other Names Used: __________________________________________________________________________ Residential Address: ________________________________________________________________________________ (Street) (City) (State ) (Zip)

Mailing Address: ___________________________________________________________________________________ (Street) (City) (State ) (Zip)

Sex: [ ] Male [ ] Female Date of Birth: _________________ Social Security #_________________________

Section B – Past Residences Within the last five (5) years, have you… 1. …lived in another state? [ ] Yes [ ] No 2. …lived on or do you now live in an area designated as an Indian reservation? [ ] Yes [ ] No If you answered yes to the any of the above questions:

Please state where you have lived since turning 18 in the table below. You will need to obtain an out of state background check or a tribal background check at your cost.

City County Reservation State Dates of Residency (From – To)

Section D – Employment Status The facility that I am working / living at is:

Director Name / Facility Name: ___________________________________________________________________

Facility Mailing Address: ________________________________________________________________________

Section E – Authorization Statement and Signature I, ____________________ (applicant name), am aware that __________________________________ (provider or its authorized representative), has requested confidential information from the Montana Department of Public Health and Human Services, in accordance with 41-3-205(3)(o), MCA as part of a review of my personal background in connection with my status as a current or prospective employee of or volunteer for that entity.

I am aware that CFSD, DMV, and DOJ records may contain information that could adversely affect my employment or volunteer status as outlined in ARM 37.97.101 through 37.97.132. These records will relate to any substantiated report(s) of child abuse or neglect in Montana, criminal history records, and motor vehicle records. As an employee or volunteer, I understand that I am also subject to the above requirements.

I am also aware that although the entities or individuals requesting and receiving confidential CFSD information are bound by law or agreement with DPHHS to protect or preserve its confidential nature, DPHHS has no ability or authority to ensure that confidentiality is maintained after this information is released by DPHHS.

In full acknowledgement of the above information and notice, I authorize CFSD to provide the requested confidential information to__________________________________________ (provider or its authorized representative), and I hereby also release CFSD from any claims or causes of action which may subsequently arise from release of this confidential information.

NOTE: Any deletions or oversights may result in the denial of your application.

Signed: _______________________________________________________________ Date: ____________________

(To be signed in front of a notary)

TO BE COMPLETED BY A NOTARY PUBLIC:

Taken, sworn, and subscribed before me this ____________ day of _________________________ A.D. ____________

_________________________________________________________ Notary Public for the State of Montana

Residing at: _______________________________________________

My commission expires: _____________________________________

Opportunity Resources, Inc.

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Opportunity Resources, Inc. at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Verified First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel. # 1-888-670-9564; www.VerifiedFirst.com and/or Opportunity Resources, Inc. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. Signature Date

PLEASE COMPLETE ALL FIELDS BELOW

Have you ever been convicted of any criminal offense (misdemeanor or felony)?

☐YES☐ NO Date of Offense ☐ Last Name First Name Middle Name check box if no middle name Social Security Number* 000-00-0000 Date of Birth* 00/00/0000 Email Address required

Driver’s License Number Issuing State* Former Names/Aliases separate aliases with comma

CURRENT ADDRESS Street Apt/Unit City State Zip PLEASE LIST WHERE YOU HAVE RESIDED FOR THE PAST FIVE YEARS. ATTACH ADDITIONAL PAGES IF NECESSARY.

CITY COUNTY STATE DATE OF RESIDENCY(month/year - month/year)

THIS INFORMATION IS REMOVED FROM YOUR APPLICATION PRIOR TO ANY SCREENING PROCESS.

FOR OFFICIAL USE ONLY

Sent Received Website

Criminal SVO

APS/CPS CON

MVR HHS-OIG