APPLICATION FOR EMPLOYMENT

Transcription

1 Administrative Offices One Arc Way Bath, NY (607) Fax (607) Bernard J. Burns, Executive Director APPLICATION FOR EMPLOYMENT All questions must be answered entirely. (PLEASE PRINT PLAINLY) PERSONAL Name Last First Middle Date Social Security No. Present address No. Street City State Zip Are you over the age of 18? Telephone No. Are you legally eligible for employment in the U.S.A.? Yes No (If yes, verification will be required at time of hire) Position(s) applied for Have you previously applied for employment with The Arc of Steuben? If yes, when? Were you previously employed by us? If yes, when? If your application is considered favorably, on what date will you be available for work? Are there any other experiences, skills, or qualifications which will be of special benefit in the job for which you are applying? (Applicant should not list any information that Federal and/or State law precludes obtaining in the pre employment stage.) RECORD OF EDUCATION School Name and Address of School Course of Study High School Check Last Year Completed College Did You Graduate? Yes No Yes No List Diploma or Degree LAST NAME FIRST MIDDLE POSITION DATE Other (Specify) Yes No

2 1. (Turn to Next Page) List below present and past employment, beginning with your most recent. ("See resume" or other such designations are NOT permissible.) Name, Address of Company and Type of From To Business Mo. Yr. Mo. Yr. Starting Last Reason for Leaving Name of Supervisor Telephone: 2. Name, Address of From To Company and Type of Business Mo. Yr. Mo. Yr. Starting Last Reason for Leaving Name of Supervisor Telephone: 3. Name, Address of From To Company and Type of Business Mo. Yr. Mo. Yr. Starting Last Reason for Leaving Name of Supervisor Telephone: 4. Name, Address of From To Company and Type of Business Mo. Yr. Mo. Yr. Starting Last Reason for Leaving Name of Supervisor Telephone: I hereby give permission to contact the employers listed above concerning my prior work experience and the educational institutions listed above concerning my academic record. Signed X If there is a particular employer(s) you do not wish us to contact, please indicate which one(s) and why. Do your previous employers know you by a different name(s)? Yes No

3 If yes, please list: MILITARY SERVICE RECORD Were you in the U.S. Armed Forces? Yes No If yes, what Branch? Did you receive any training in the U.S. Armed Forces that is relevant to the position applied for? PERSONAL REFERENCES (Not Former Employers or Relatives) (REQUIRED) Name and Occupation Address Phone Number OTHER (Please read and sign below.) I understand that the processing of my employment application requires the expenditure of time and resources by this employer. I also understand that this employer would not process this application if I had no genuine interest in employment with this employer at the time this application is submitted. Therefore, I hereby represent and certify that I am genuinely and sincerely interested in employment with this employer and that my application is submitted in good faith and without false pretenses in furtherance of my sincere and genuine interest in employment with this employer. Additionally, I attest that the facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I further understand that this application is not and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. I understand and agree that my employment is at will and can be terminated by either party with or without notice, at any time, for any reason or no reason. No one other than an officer to the Company has any authority to enter into agreement for employment for any specified period of time or to make any agreement contrary to the forgoing and then only in writing signed by an officer. X Signature of Applicant To Applicant: READ THIS CAREFULLY: The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, cred, religion, sex, or national origin. Federal law also prohibits other types of discrimination such as age, citizenship, disability, veteran status, attainment of benefits, and participation in union activities. The laws of most states and many localities also prohibit some or all of the above types of discrimination as well as some additional types including, but not limited to, discrimination based upon ancestry, marital status, parental status, sexual orientation, or source of income. The Fair Credit Reporting Act imposes restrictions with respect to credit data.

4 FOR EMPLOYER'S USE ONLY (Must be completed for all applicants interviewed.) 1. Human Resources Department Completes: Applicant's Name: Interviewers: Position under consideration: Date: Follow up actions required: Recommend follow up interview with: Applicant unacceptable for job under consideration. Reconsider for job as: Notify applicant of rejection on: Additional comments: ******************************************************************************************************************* 2. Team Leader Completes After Second Interview: Interview(s): Position Title: Schedule (weekly): Total number of hours (weekly): Proposed Start Date: Non Exempt Exempt Full Time Part Time Cost Center Code: Position Title Code: Team Leader: Hourly Wage: Reason for hiring: Applicant unacceptable for job under consideration. Reconsider for job as: ******************************************************************************************************************* 3. Attachments (Please Initial): HRD=Human Resources Dept. TL=Team Leader Resume (HRD) Criminal Conviction Statement (HRD) Driving Record Statement (HRD) Initial Interview (HRD) Seat Belt Acknowledgement (HRD) Personal References (HRD) Second Interview (TL) Employment Reference Verification (HRD) Child Abuse Form (HRD) Other: Human Resources Dept.: Date: Team Leader: Date:

5 Source: Human Resources A 1,007 Application for Employment (10/00) Public/Agency Wide Forms/A 1,007 EMPLOYMENT APPLICATION SUPPLEMENT Criminal Conviction Statement Have you ever been convicted of a misdemeanor or a felony in any jurisdiction, excluding traffic offenses? Yes No If yes, describe in full. Federally Sponsored Health Care Program Exclusion Statement Are you now, or have you ever been excluded from participating in a federally sponsored health care program such as Medicare or Medicaid? Yes No If yes, please describe the circumstances and indicate the period of exclusion. The facts set forth above are true and complete. I understand that if employed, any false statement on this supplement may result in my dismissal. Name: Department: Please print or type Signature: Date: NOTE: CRIMINAL CONVICTIONS ARE NOT AN ABSOLUTE BAR TO EMPLOYMENT AND WILL ONLY BE CONSIDERED IN RELATION TO SPECIFIC JOB REQUIREMENTS. File: Source: HR Personnel File A 1,008 Criminal Conviction Statement, Rev Public/AgencyWide Forms/A 1,008

6 SEAT BELT ACKNOWLEDGMENT New York State Law requires that a seat belt be worn while operating a motor vehicle. The Arc of Steuben abides by this law. When associates operate Agency vehicles, or their own vehicles for Agency business, wearing a seat belt is required. I have read an understand the above statement, and I will follow its requirements. Name: Department: Please print or type Signature: Date: File: Personnel File A 1,009 Rev.10/00 Source: PER/HR Schared/Forms/A 1,009

7 EMPLOYMENT APPLICATION SUPPLEMENT Driving record Many positions at the Arc of Steuben require driving Agency vehicles and transporting program participants. In order to meet our insurance carrier s requirements, please complete the following questions. 1. Do you have a valid NYS driver s license? Yes No If yes, what class license do you hold? Have you had a valid license for a minimum of three years? Yes No 2. Have you been involved in an accident which resulted in property damage or Physical injury? Yes No If yes, complete the following: a. Date of accident: b. Location of accident: c. Extend of property damage: d. Number of people injured: e. Number of people confined to a hospital: 3. During the past three (3) years have you been convicted of any moving traffic violations? Yes No Have you ever had your license suspended and/or revoked? Yes No Have you ever been convicted of driving while intoxicated (DWI)? Yes No If yes to any of the above, complete the following: Date of violation Date of conviction Charge Violation The facts set forth above are true and complete, I understand if employed my driving record may be requested from the state in which I am licensed to drive. I also understand that if employed, any false statement on this supplement may result in my dismissal. Name: Signature: Date: Please Type or Print A 1,010 Rev. 10/00

8 Source: Per/HR Shared/forms/A 1,010 EMPLOYMENT APPLICATION SUPPLEMENT Referral Method Name: Date: Position Applied For: How did you hear about the job for which you applied: (check one) Newspaper Radio Department of Labor/Job Service The Arc of Steuben website Current Arc of Steuben Associate (name) Other (specify) A 1,010a Rev. 10/00 Source: Per/HR shared/forms/a 1,010a

9 Pre Employment Questionnaire To assist us with ensuring excellent services are continually provided to the people we serve, please respond to at least four (4) of the following questions as part of our pre employment screening process. 1.) Describe a past crisis experience in your life and how you responded to this crisis. 2.) What kinds of things make you angry? 3.) If you have a problem with a co worker, how do you handle it? 4.) If you were having trouble getting along with a person you were serving, how would you handle it? 5.) Describe a situation where you were criticized and how you responded to this criticism. 6.) Do you prefer to work by yourself or as part of a team? Why? 7.) When you meet/see a person who has a disability, what are your initial feelings and/or reactions? 8.) How did you become interested in this field?

10 9.) What do you feel are the differences between you and the people served by the Arc of Steuben? 10.) What do you aspire to be professionally? 11.) What in your life has brought you the greatest joy? 12.) If you had to create a unique slogan, which describes your greatest attribute, what would it be? 13.) Write a brief narrative of the most important moment in your life and the impact it had on you as a person. 14.) How do you interpret the word family? 15.) How would you handle a situation in the community where a person was rude or insulting to the needs of a person with a developmental disability? 16.) Identify a hurdle/challenge you have faced and how you handled/overcame it. 17.) If you had to do something differently in your life, what would it be and why.

11 Source: Human Resources A 1,054 Pre employment Questionnaire, 8/01/01 Public/AgencyWide Forms/A 1,054

12 Send all pages, completed and signed, to ATTN: Human Resources The Arc of Steuben One Arc Way Bath, NY OR FAX to: , ATTN: Human Resources