NAME: DATE:
EMAIL:
OTHER NAMES (IF APPLICABLE):
STREET ADDRESS:
CITY: STATE: ZIP:
PRESENT PHONE - HOME: WORK:
LENGTH OF TIME AT PRESENT ADDRESS:
UPON AN OFFER OF HIRE, ARE YOU ELIGBLE FOR EMPLOYMENT IN THE UNITED STATES Yes No
ARE YOU AT LEAST 21 YEARS OF AGE? Yes No
PRESENT OCCUPATION:
POSITION APPLYING FOR:
TYPE OF WORK: Full-Time PartTime Summer Work
SALARY DESIRED:
DATE AVAILABLE:
DAYS & HOURS AVAILABLE:
WORK LOCATION RESTRICTIONS (IF ANY):
HAVE YOU EVER APPLIED TO THIS ARC BEFORE OR WORKED WITH AN ARC GROUP? No Yes
IF YES, WHEN OR WHERE?:
REFERRAL SOURCE:
HAVE YOU EVER BEEN CONVICTED OF A FELONY? No Yes

HAVE YOU EVER BEEN ADJUDGED CIVILLY OR CRIMINALLY LIABLE FOR ABUSE OF A DEVELOPMENTALLY DISABLED PERSON RECEIVING SERVICES FROM THE DEPARTMENT OR PLACED IN A COMMUNITY RESIDENCE REGULATED BY THIS CHAPTER? No Yes

IF YOU ANSWERED YES TO EITHER OF THE ABOVE, GIVE DATE, PLACE AND DISPOSITION OF CASE:

EMPLOYMENT HISTORY – List most recent employer first.

Most Recent Employer
EMPLOYER: PHONE:
ADDRESS:
TYPE OF BUSINESS:
DATES EMPLOYED - FROM: (MO/YR): TO: (MO/YR):
STARTING POSITION: STARTING SALARY:
ENDING POSITION: ENDING SALARY:
NAME AND TITLE OF YOUR MOST RECENT IMMEDIATE SUPERVISOR:

SUMMARY OF DUTIES OF YOUR MOST RECENT POSITION:

REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER? Yes No

Previous Employer
EMPLOYER: PHONE:
ADDRESS:
TYPE OF BUSINESS:
DATES EMPLOYED - FROM: (MO/YR): TO: (MO/YR):
STARTING POSITION: STARTING SALARY:
ENDING POSITION: ENDING SALARY:
NAME AND TITLE OF YOUR MOST RECENT IMMEDIATE SUPERVISOR:

SUMMARY OF DUTIES OF YOUR MOST RECENT POSITION:

REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER? Yes No

Previous Employer:
EMPLOYER: PHONE:
ADDRESS:
TYPE OF BUSINESS:
DATES EMPLOYED - FROM: (MO/YR): TO: (MO/YR):
STARTING POSITION: STARTING SALARY:
ENDING POSITION: ENDING SALARY:
NAME AND TITLE OF YOUR MOST RECENT IMMEDIATE SUPERVISOR:
SUMMARY OF DUTIES OF YOUR MOST RECENT POSITION:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER? Yes No

EDUCATION

HIGHSCOOL

SCHOOL NAME:
ADDRESS:
DATES ATTENDED:
MAJOR: DIPLOMA RECEIVED:

COLLEGE
SCHOOL NAME:
ADDRESS:
DATES ATTENDED:
MAJOR: DIPLOMA RECEIVED:

GRADUATE
SCHOOL NAME:
ADDRESS:
DATES ATTENDED:
MAJOR: DIPLOMA RECEIVED:

OTHER
SCHOOL NAME:
ADDRESS:
DATES ATTENDED:
MAJOR: DIPLOMA RECEIVED:

List professional accomplishments, affiliations and activities, including memberships in professional or technical organizations, papers published, etc.:

REFERENCES

List the names of 4 person not related to you who are familiar with your work habbits and character

(2 professional, 2 personal)

PROFESSIONAL:

NAME: POSITION:
PHONE:

NAME: POSITION:
PHONE:

PERSONAL

NAME: PHONE:

NAME: PHONE:

TRAINING HISTORY

List below the dates of any organized trainings you have completed which are relevant to employment with persons with Developmental Disabilities

CPR:
FIRST AID:
OTHER:

By submitting this application, I hereby affirm that my answers to the foregoing questions are true and correct and I understand that misrepresentation or omission of facts called for in the application may be cause for immediate dismissal without notice. If employed, I agree to conform to, and accept the Personnel Policies of The Arc of Somerset County. I understand that if offered employment by this agency, such employment may be terminated at anytime with or without cause or reason, by the employee or the company.

I hereby authorize inquiry of any company, person or institution by The Arc of Somerset County to gain information with regard to my employment, character and ability which they may have on record, or otherwise; and hereby release such individuals from all liability, holding them harmless from any information they provide.

The Arc of Somerset County is an EQUAL OPPORTUNITY EMPLOYER - M/F/V/D