PLEASE READ ENTIRE APPLICATION BEFORE FILLING OUT THE APPLICATION.

Transcription

1 PLEASE READ ENTIRE APPLICATION BEFORE FILLING OUT THE APPLICATION. EASTER SEALS NEVADA EMPLOYMENT APPLICATION 6200 W. OAKEY BLVD. LAS VEGAS, NV Phone: Fax: address: or Website address: Position(s) applied for: Date of Application: Last name: First Name: Middle Name: Address: Apt. /Unit #: City: State: Zip Code: Cell phone number: Home phone number: address How did you hear about Easter Seals Nevada? (Circle one.) Newspaper Ad Employment Agency Current Employee Job Fair Other: Are you legally eligible to work in the United States? YES NO (Proof of eligibility will be required upon offer of employment.) Are you over the age of 18 years? YES NO (If no, you may be required to provide authorization to work.) Can you, with or without reasonable accommodation, perform the essential functions of this job? (If you have any questions about the functions of the job, please ask the receptionist before answering this question.) YES NO Have you ever worked for or applied to work for ESN? YES NO If YES, please show: Dates of employment: or Date of application: Are you seeking full time or part time employment? [ ] full time [ ] part time Have you ever been convicted of a crime? YES NO You are not obligated to disclose sealed, annulled or expunged convictions or convictions pardoned by the governor. Please be aware that a criminal conviction will not necessarily be a bar to employment and will be considered as it relates to the job in question. Some convictions will disqualify you from employment with ESN no matter when they occurred; some convictions will disqualify you if they occurred within the last 7 years. (See Nevada Revised Statute NRS ) Please list ALL convictions (no matter when they occurred) with the exception of any sealed, annulled or expunged convictions or convictions pardoned by the governor. Failure to honestly and completely answer this question will result in discontinued consideration of the application or termination of employment. If yes, please indicate county and state where convicted: Date convicted / / Please explain the nature of the conviction/s: (Attach a separate sheet if necessary or if more than one conviction.) Is anyone related to you employed by ESN? YES NO If YES, please give their name: and relationship to you: 1

2 What salary or rate of pay do you expect to receive if employed? $ per. Previous salaries or wages will not be used to determine compensation at ESN. Have you ever been discharged from a job or asked to resign from a position? YES NO If YES, please explain: On what date would you be available to start work? / / If hired, which days and hours would you be available to work? Fill in the chart below. Days and Hours Available: Day Sunday Monday Tuesday Wednesday Thursday Friday Saturday AM PM EDUCATION: Elementary High School College Graduate Vocational Name & Location of School Course of Study or Major # of years completed Diploma / Degree Please list any academic honors, scholarships, offices held, etc. Describe any specialized training, apprenticeships, licenses or skills: Have you received any job-related training in the United States Military? YES NO Please give dates and explanation: Have you ever worked at an agency or agencies with individuals who were from DRC (Desert Regional Center) or SNAMHS (Southern Nevada Adult Mental Health Services): Circle one: YES NO If yes, please provide the name/s of the agency/agencies you worked for and the dates you were employed by them. If more than three, please attach a separate sheet. These agencies WILL be contacted, in addition to other employment references. Agency: Dates employed: Agency: Dates employed: Agency: Dates employed: 2

3 EMPLOYMENT HISTORY: (Please provide at least a 5 year history, beginning with current or most recent employer. Do not exclude any employment. Include any applicable temporary employment. Also show all periods of unemployment. (If period of unemployment put Unemployed in block labeled Company Name and dates of unemployment in block labeled Employment Dates.) Attach another employment history sheet if necessary. (The receptionist can provide another sheet.) Company Name Employment Dates (Show Month & Year) Location (City & State): From: To: Start End Name and Title of Supervisor Phone Number: Reason for Leaving and Explanation: Describe your duties: Company Name Employment Dates (Show Month & Year) Location (City & State): From: To: start End Name and Title of Supervisor Phone Number: Reason for Leaving and Explanation: Describe your duties: Company Name Employment Dates (Show Month & Year) Location (City & State): From: To: start End Name and Title of Supervisor Phone Number: Reason for Leaving and Explanation: Describe your duties: 3

4 REFERENCES: Please provide the information on three individuals who would be willing to comment on your suitability for a position with ESN. IMPORTANT: At least two of the references must be business related. Personal reference cannot be a relative. Reference Type Company Name and First and Last Name Of Reference Address (City / State) Phone Number(s) Relationship / Occupation / title Years Known BUSINESS BUSINESS PERSONAL (no relatives) Note: Some of our Programs require that staff possess the following: (To be considered for those Programs, please answer yes or no for each question.) Reliable Transportation YES NO A Valid Drivers License YES NO State of Issue: Proof of Current Vehicle Registration YES NO Proof of Vehicle Insurance YES NO Have you been convicted of any moving violations in the past five years? YES NO If YES, please provide Type, Date, and Location (City & State) of each violation: Please list all languages in which you are fluent: Language: Circle all that apply Speak Read Write Speak Read Write Speak Read Write Speak Read Write American Sign Language? Yes No 4

5 Please respond to the following questions as completely as you can. Please use complete sentences. 1. How did you hear about ESN and why do you want to work here? 2. Please describe any experiences in your life that have increased your awareness and understanding of individuals with disabilities. 3. If you were employed by ESN, what would you do to increase community awareness of the needs of persons with disabilities and increase community awareness of ESN? 4. Why should we hire you? 5

6 APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION *****PLEASE READ CAREFULLY BEFORE SIGNING***** I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. Submission of an application does not guarantee employment. Should an offer of employment be extended by EASTER SEALS NEVADA (hereinafter referred to as ESN ), such employment with ESN is employment at-will, for no specified duration and may be terminated by either ESN or the employee at any time, with or without cause or notice. None of the documents, policies, procedures, actions, statements of ESN or its representatives used during the employment process is deemed a contract of employment real or implied. No representative of ESN except the President/C.E.O. has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President/C.E.O. of ESN. If I am employed by ESN, I agree to comply with the rules, regulations, policies and procedures of ESN at all times and understand that such compliance is a condition of employment. Due to the nature of ESN business, attendance and punctuality are essential requirements of every job at ESN and that poor attendance or tardiness will result in disciplinary action up to and including termination of employment. I understand that if offered a position with ESN, I may be required to submit to a pre-employment medical examination, instant background check, drug and alcohol screening, and State and FBI fingerprint checks as a condition of employment. Unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employment tests and checks will result in the withdrawal of any employment offer or the termination of employment if already employed. Individuals who attempt to alter a drug or alcohol test result or a test sample by means of tampering with, adulterating, switching, or diluting a specimen will be treated as if they had a positive test result. A positive test result will result in the withdrawal of any employment offer or the termination of employment if already employed, except in circumstances of a confirmed, legal drug prescription issued by a medical professional. A prescription for medical marijuana is not included; testing positive for marijuana or marijuana metabolites will result in the withdrawal of any employment offer or the termination of employment if already employed. I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to ESN and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application. BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS. Signature of Applicant Date Print Name of Applicant Name and Number of person completing this form if other than applicant: Name Phone Number ESN IS PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, DISABILITY, AND VETERANS STATUS AND/OR ANY OTHER STATUS PROTECTED BY LAW. 6

7 Contract Provider Employee Application Supplemental Questions Easter Seals Nevada is a certified and/or approved contract provider of the Nevada Developmental Services (DS) Regional Center. The Nevada DS Regional Centers require that all employee applicants complete the following questions: 1) Have you ever worked with any agency which contracts with the State of Nevada Developmental Services Regional Centers (Desert, Rural or Sierra Regional Center)? Yes No 2) Have you ever worked for an agency, either within or outside, of the State of Nevada that serves a vulnerable population e.g. children, seniors or developmentally disabled? Yes No 3) Have you ever been the accused (placed on re-assignment/administrative leave) in an abuse, neglect or exploitation complaint and/or investigation? Yes No If so, were the accusations confirmed or substantiated? Yes No If yes, what was the out come? (Check all that apply.) Termination Suspension Retraining Other Describe: I declare that the information provided to the above questions is true and complete. Print Name Signature Date DS-QA-30 (2/19/10) 7

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