* = Required Information
We are an Equal Opportunity Employer and consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
Date of Application
*
Position(s) applied for
*
Please read the minimum qualifications of the job announcement before completing this application. You must meet all qualifications to be considered for the position.
How did you learn about us?
Date Available
Minimum acceptable salary
Available for
Full time
Weekends
On Call/Substitute
Part time
Live-in
Evenings
Temporary
Overnights
Mornings
List hours/day available
Name
*
Address
*
Number
Street
City
State
Zip Code
Home Phone
*
Cell Phone
*
Social Security Number
Email Address
*
Person(s) to contact in case of emergency:
Name
Home Phone
Other Phone
Relationship
Name
Home Phone
Other Phone
Relationship
Have you filed an application before?
Yes
No
If yes, give date
Which program
Position
Are you authorized for employment in this country?
Yes
No
(Proof of U.S citizenship or immigration status will be required upon employment.)
Have you been convicted?
Yes
No
(Conviction will not necessarily disqualify an applicant from employment.)
If yes, please explain.
Does your name appear on the List of Excluded Individuals/Entities (LEIE), a database of parties excluded from participation in Medicate, Medicaid and all federal health care programs?
Yes
No
Do you have a valid driver's license?
Yes
No
What State?
Driver's license number
Do you have any violations on your driving record?
Yes
No
If yes, please explain.
Have you ever worked with individuals with intellectual and/or developmental disabilities?
Yes
No
Have you ever been dismissed or asked to resign by a previous employer?
Yes
No
EMPLOYMENT HISTORY
Please do not submit a resume in lieu of completing this portion of the application. List your last (4) employers, assignments or volunteer activities starting with the most recent, including military experiences. Explain any gaps in employment in comments section.
(1)
Employer
*
Telephone
*
Address
*
Job Title
*
Immediate Supervisor and Title
*
Dates Employed
From
To
Hourly Rate / Salary
Starting
Final
Reason for Leaving
May we contact for references?
Yes
No
Later
Summarize the nature of the work performed and job responsibilities
(2)
Employer
Telephone
Address
Job Title
Immediate Supervisor and Title
Dates Employed
From
To
Hourly Rate / Salary
Starting
Final
Reason for Leaving
May we contact for references?
Yes
No
Later
Summarize the nature of the work performed and job responsibilities
(3)
Employer
Telephone
Address
Job Title
Immediate Supervisor and Title
Dates Employed
From
To
Hourly Rate / Salary
Starting
Final
Reason for Leaving
May we contact for references?
Yes
No
Later
Summarize the nature of the work performed and job responsibilities
(4)
Employer
Telephone
Address
Job Title
Immediate Supervisor and Title
Dates Employed
From
To
Hourly Rate / Salary
Starting
Final
Reason for Leaving
May we contact for references?
Yes
No
Later
Summarize the nature of the work performed and job responsibilities
Comments
(including explanation of any gaps in employment):
EDUCATION
(1)
Name of School and location
Type of Diploma or Degree Awarded
Dates Attended
Major Field
(2)
Name of School and location
Type of Diploma or Degree Awarded
Dates Attended
Major Field
(3)
Name of School and location
Type of Diploma or Degree Awarded
Dates Attended
Major Field
(4)
Name of School and location
Type of Diploma or Degree Awarded
Dates Attended
Major Field
In the space provided, list any job-related professional organizations to which you belong, honors or awards you have received, etc. or other experiences relevant to the postion for which you have applied.
Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our agency.
Are you related to any current employees of The Arc County?
Yes
No
If yes, give name, relationship and program.
REFERENCES
List name and telephone number of three business/work references who are NOT related to you and NOT previous supervisors. If not applicable, list three school or personal references who are NOT related to you.
Name
*
Daytime telephone number
*
Years known
*
Submit