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Application

Application for Employment

Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

999-999-9999
999-999-9999
Community Support Aide #1729
Direct Support Professional- Floater #1701
Janitor - RA Preble Part Time #1709
DSP (Direct Support Professional) #1721
Machine Set-Up Operator- #1720
Behavior Specialist #1717
Production Associate #1724
Janitor Whitney Point Rest Area #1737
OraLine - Graphic/Production Artist #1732
Team Leader, Team #9 - #1739
Team Leader, Team #5 - #1741
Office Assistant/Receptionist - #1742

Other:
mm/dd/yyyy
Walk-In
Employee
Advertisement
Company's Website
Other Internet
School
Job Fair
Staffing Agency
Government Employment Agency
Other
(include am or pm)
At which number? Home Mobile/Other

Yes No
If yes, work number and best time to call:

(include am or pm)

Yes No


Yes No


Yes No
If yes, please give date(s):




Yes No

Yes No
mm/dd/yyyy

$
Full-Time
Part-Time
Temporary

Yes No

Yes No

N/A
Yes
No

Yes No


Yes
No
Need more information about the job's "essential functions" to respond
Driver's license number required if driving may be required in the job for which you are applying:


Yes No
Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Yes No


Yes No

Employment History

Employer 1
Begin with your current or most recent employer.
You may include any verified work performed on a volunteer basis
999-999-9999
(for most recent position)
Yes No Later

per



Employer 2
You may include any verified work performed on a volunteer basis
999-999-9999
(for most recent position)
Yes No Later

per



Add another employer


Yes No

Skills and Qualifications




Word Processing
Software Titles:
Years:
Spreadsheet
Software Titles:
Years:
Email/Internet
Software Titles:
Years:
Other
Software Titles:
Years:

Educational Background

School 1
Begin with your current or most recent school attended.
Diploma
GED
Degree:
Certification:
Add another school

References

List names and telephone numbers of two professional references and two personal references who are not related to you and are not previous supervisors. If not applicable, list school or personal references who are not related to you.

Professional Reference 1
999-999-9999
Professional Reference 2
999-999-9999
Personal Reference 1 (non-relative)
999-999-9999
Personal Reference 2 (non-relative)
999-999-9999

Related Information



Resume

Upload a Word, WPS or PDF copy of your resume.

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

DO NOT CHECK THE BOX UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

Please click submit only once. It may take up to 30 seconds to collect your information. You will receive an on-screen confirmation when complete.