APPLICATION FOR EMPLOYMENT

Transcription

1 APPLICATION FOR * Janus Developmental Services, Inc. is an equal opportunity employer. Applicants are considered for employment without regard to race, color, national origin, religion, sex, age, disability, citizenship status, or any other basis prohibited by law, unless such basis constitutes a bona fide occupational qualification. PLEASE PRINT Date: Name: LAST FIRST MIDDLE Address: NUMBER STREET CITY STATE ZIP CODE Home Phone: Business/Cell Phone: Are you over the age of 18? Referred By: DESIRED: Have you ever applied for employment with us? Yes No If yes, Month and Year: Position Desired: Salary Desired: Are you interested in: Full-time Part-time Temporary Will you work overtime if asked? Yes No When will you be available to begin work? Are you a U.S. Citizen or an alien legally entitled to work in the position for which you have applied? Do you have any relatives employed by Janus? If yes, please list them by name EDUCATION 1

2 Grammar School Number of Graduate? Course Pursued Years Degrees Granted School/ Institution City and State Completed Yes No High School College or University Other Schools MILITARY: This section MUST be completed, if does not apply please mark N/A Branch of Service: Rank at Discharge: Period of Active Duty: (month and year) From: To: Date of Final Discharge: Describe your duties and any special training: SPECIAL SKILLS: Summarize any special job-related skills and qualifications acquired from education, employment, or volunteer work: List specific office machines, tools, machinery, or other equipment that you have been trained on and can operate that will be helpful in performing the responsibilities of the position for which you are applying : Please give accurate, complete full-time and part-time employment records. Start with present or most 2

3 recent employer. We may contact the employers listed above unless you indicate those you do not want us to contact. DO NOT CONTACT: (S) REASON REFERENCES: List three references who are NOT related to you and who you have known for at least one year. 3

4 Name Address Phone Number Years Acquainted PHYSICAL RECORD: In case of emergency notify: Address: FIRST LAST STREET CITY STATE ZIP CODE Home Phone: Business/Cell Phone: Do you have a current Mantoux/TB or chest x-ray? Yes No Have you been tested for drug and alcohol by The Department of Transportation in the past 2 years? If Yes, Name Company and Supervisor Have you been convicted of a felony or misdemeanor (other than a minor traffic violation)? (Conviction will not necessarily disqualify applicant from employment) If yes, please explain: Please provide any additional information you believe would be helpful in considering your application. 4

5 Applicant s Statement (please indicate the you have read and understand each paragraph of the Applicant s Statement by placing your initials beside each paragraph.) I certify that this application was completed by me and that all entries on it and all information in it are true and complete to the best of my knowledge. In the event of employment, I understand that any false, misleading, inaccurate or omitted information in my application may result in discharge. I authorize the Agency to investigate the statements contained in this application, including interviewing the personal references and past employers listed. This inquiry may include information as to my character, general reputation, and personal characteristics, as well as information about my work performance and workplace conduct. I agree to submit to a drug test and understand that any offer of employment is contingent upon the results of that examination. I understand that, according to federal law, all individuals who are hired must, as a condition of employment produce certain documentation to verify their identity and United States citizen status or, if aliens, their legal authorization to work in the United States. As a consequence, I understand the any offer of employment by the Agency would be contingent upon my ability to produce the required documentation within the time period required by law. I understand that this application is not, and is not intended to be, a contract of employment and that any resulting employment relationship is for no fixed period of time and is terminable at any time and for any reason by the Agency or by me. I further understand the statements which may be contained in policies, handbooks, or other agency material does not create any guarantee of employment and the Agency has the right to modify, amend or terminate policies, benefit plans, or other programs within the limits and requirements imposed by law. I understand that no representative of the agency has the authority to enter into any agreement for any specific period of time or to make any agreement contrary to the foregoing. Further, I understand that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice. Applicant Signature Date 5