DSP Application for Employment

(605) 347-4467

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Black Hills Special Services Cooperative
PO Box 218 Sturgis, SD 57785 | 737 University Avenue Hot Springs, SD 57747 | 730 E. Watertown, Rapid City, SD 57701
EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
"Special accommodations for application, training, or job information in alternative formats available upon request"
Job Location
- DD Division Northern Hills - Sturgis, SD
- DD Division Southern Hills - Hot Springs, SD
Name*
First Middle Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Telephone Number*
Email*
If hired can you furnish proof that you are eligible to work in the United States? If no, please explain.*
(If unsure of the documents needed to prove eligibility to work in the US, we will be happy to explain the legal requirements.)
Males born after December 31, 1959 are required to register with the Selective Services. Are you registered with the Selective Services?*
- Yes
- No
Do you wish to claim veteran's preference? If yes, DD-214 (separation papers) must be attached. If you are a disabled veteran, attach current VA disability certification with DD-21 (separation papers)*
- Yes
- No
State law requires residency in South Dakota to be eligible to receive veteran's preference. Are you currently a resident of the state of South Dakota?*
- Yes
- No
Will you accept:*
- Full-time Employment
- Part-time Employment
Have you worked for BHSSC in the past? If yes, please give dates of employment, positions held, and state your name while employed, if different than present name.*
Many positions within the Black Hills Special Services Cooperative require lifting of up to 50 pounds, are you able to fulfill this duty if your position requires?*
- Yes
- No
References: List references. Please do not list any relatives. Providing this information means that you give the organization permission to contact the references listed.*
Name Complete Address Daytime phone number and best time to contact Fax No.
*
Name Complete Address Daytime phone number and best time to contact FAX No.
*
Name Complete Address Daytime phone number and best time to contact FAX No.
*
Name Complete Address Daytime phone number and best time to contact FAX No.
Have you ever been convicted of a felony, or released from prison in the past 10 years? Note: A yes answer does not automatically disqualify you from employment since the nature of the offense, date and type of job for which you are applying will be considered. If yes, please explain.*

Please answer the question below
Please Read and Sign Below
I give my consent to any pre-employment physical examination required by this company after any conditional offer of employment has been made. If employed, I understand that my employment is for no definite period of time, and if terminated the employer is liable only for wages earned as of the date of termination. I hereby certify that the information given by me is true and complete to the best of my knowledge and belief. I further authorize investigation of all statements I have made. Misrepresentations, falsification, or omission of facts called for in this application or in the interview process are cause for cancellation of this application or termination of employment. Unsigned applications will not be considered.
Signature*
Date (dd/mm/yyyy)*
DD slash MM slash YYYY
Authorization for reference requests (sign below).
I have applied with Black Hills Special Services Cooperative for employment and I desire that they be fully advised of my record with former employers. I, therefore, respectfully request that you furnish the requested information concerning my employment with your organization, and hereby release you from any and all liability of damages for providing the information requested.
Signature*
Date (dd/mm/yyyy)*
DD slash MM slash YYYY
Black Hills Special Services Cooperative, in accordance with state and federal laws, does not discriminate on the basis of age, race, color, ancestry, national origin, creed, religion, sex, marital status, disability, or any other protected class.
Black Hills Special Services Cooperative recognizes that South Dakota is an employment at-will state and maintains the employment at-will status for all employees.
Please contact the BHSSC department advertising this position to determine if you must also complete the following form as part of your application:
SOUTH DAKOTA PERMISSION TO SCREEN FOR REPORTS OF ABUSE OR NEGLECT

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Equal Opportunity Employer

It is the policy of BHSSC not to discriminate on the basis of any protected group status in its educational programs, activities, or employment policies and activities as required by following state and federal laws and regulations. Inquiries regarding non-discriminatory policies in employment may be directed to the EEO Officer, Personnel Specialist, Executive Director, and/or any Division Director at BHSSC.

South Dakota School District

BHSSC is governed by elected school board members representing 12 South Dakota school districts and provides public educational services to Pre-K-12 students.