The Arc of San Diego · service, self-employment, volunteer experience, time in school, and periods...
Transcript of The Arc of San Diego · service, self-employment, volunteer experience, time in school, and periods...
HRF-004/Rev. 01.01.2011
Position Applied for : ______________________________________________________ Date: _______________________
The Arc of San Diego Employment Application
Name Email Address Last First Middle Initial
Address Street City State Zip
Home Phone Work Phone Cell Phone
REFERRAL SOURCE: Please Check One
Newspaper Name: EDD/Cal Jobs Name:
Trade Publication Name: Employee Name:
Internet Name: Friend Name:
Walk-in Other (Please list)
SCHEDULE PREFERRED: (Check All That Apply)
Full-Time Part-Time On-Call/Temporary Work
If hired, on what day can you start? ____________________________
PERSONAL INFORMATION
Yes No Yes No
Have you ever been employed by The Arc of San Diego? If yes, please indicate when and where, name of former Supervisor and reason for leaving?
Do you have any relatives working for The Arc of San Diego? If yes, list names and relationship:
If hired, are you able to provide documentation required by the Immigration Reform and Control Act of 1986 to verify your right to work in the United States?
Are you at least 18 years old? (If under 18,your employment is subject to verification
that you are of minimum legal age.)
If hired, would you have reliable means of transportation to and from work?
Do you have a current valid Driver’s License? Driver License # State Exp Date Class
Is there any reason you would not be able to operate a motor vehicle to transport Arc employees, consumers or equipment if required?
Are you insurable?
YES NO
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? If No is checked, are there any accommodation(s) which would enable you to perform those job functions? Please describe the accommodations. (Note: we comply with the
ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Please advise us if any accommodation is needed to participate in the application process.) ______________________________________________________
HRF-004/Rev. 01.01.2011
Have you ever been convicted of a felony or misdemeanor (Exclude convictions for marijuana-related offenses more than two years old; convictions that have been sealed, expunged or legally eradicated) If yes please explain: _______________________________________________________________________________________________
YES NO
EDUCATION AND SKILLS
Circle or enter highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16+
School Location Major Diploma/GED Did you graduate?
(circle or check)
PROFESSIONAL CERTIFICATIONS/LICENSES
Name of Certification/License Location Expiration
Date Certification/License Number
LANGUAGE SKILLS
WORK HISTORY: List your paid or unpaid work experience in consecutive order with present or last employer listed first. Include military service, self-employment, volunteer experience, time in school, and periods of unemployment. If additional space is needed, attach additional sheets. APPLICANTS MUST FILL OUT THIS SECTION EVEN IF ATTACHING A RESUME. (If discharged from the military, please only list if you were adjudicatively discharged under “reason for leaving.”)
Name of Most Recent Employer From To Phone
Address Supervisor
Job Title
Duties/Responsibilities
Reason for Leaving
May we contact this employer for a reference?
Employer From To Phone
Address Supervisor
Job Title
Duties/Responsibilities
______________________________________ Speak Read Write
______________________________________ Speak Read Write
______________________________________ Speak Read Write
Yes / No
Yes / No
Yes / No
HRF-004/Rev. 01.01.2011
Reason for Leaving
May we contact this employer for a reference?
Employer From To Phone
Address Supervisor
Job Title
Duties/Responsibilities
Reason for Leaving
May we contact this employer for a reference?
Employer From To Phone
Address Supervisor
Job Title
Duties/Responsibilities
Reason for Leaving
May we contact this employer for a reference?
Employer From To Phone
Address Supervisor
Job Title
Duties/Responsibilities
Reason for Leaving
May we contact this employer for a reference?
REFERENCES: List below persons not related to you who have knowledge of your work performance and/or general character.
Name Title
Address City State Zip
Relationship Phone
Name Title
Address City State Zip
Relationship Phone
HRF-004/Rev. 01.01.2011
Name Title
Address City State Zip
Relationship Phone
PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW
______ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if it is discovered after I am employed, regardless of the time elapsed before discovery.
______ I hereby authorize The Arc of San Diego and /or its agents to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work and/or school records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
______ I acknowledge that employment with The Arc of San Diego, is entirely on an at-will basis and receipt of this application does not imply that I will be employed, nor is it a contract for employment. I understand that I can quit employment and that I can be terminated from employment at any time, for any reason or for no reason, with or without notice. I further understand and agree that the at-will nature of my employment, if offered, cannot be altered except by a writing signed by the Chief Executive Office or his/her designee.
Applicant Signature _______________________________________________________ Date ___________________________
Equal Opportunity Statement
All qualified employees and applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. The Arc of San Diego is an equal opportunity employer Minorities/Females/People with Disabilities/Protected Veterans/Sexual Orientation/Gender Identity.
If you'd like more information about your EEO rights as an applicant under the law, please download the available EEO is the Law. EEOis the Law English Version - Revised November 2009. EEO is the Law and EEO is the Law Supplement English Version - RevisedSeptember 2015. For Spanish employees and applicants, EEO is the Law Spanish Version - Revised November 2009. EEO is the Law and EEO is the Law Supplement Spanish Version - Revised September 2015.
The Arc of San Diego’s Core Values:
People First, Person-Centered One Team Community Partnership
Excellence Integrity & Accountability