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215 West White Horse Pike Berlin, NJ 08009 APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer I certify that the information given in this application is true Last, First, Middle Name Name Email Date Referred By Address City, State, Zip Home Phone: Cell Phone: Circle One: Employment Desired Full Time / Part Time / Substitute Position Applied For If Yes Where? Are You Currently Employed? ___Yes ___No Do You Have Reliable Transportation? ____Yes ____No Do you possess valid NJ Driver’s License ____Yes ____No Other State___ What Professional License Do You Have? License / Certification Number 1. 2. 3. State of License 1. 2. 3. ____CNA ____ CHHA ____ LPN OTHER:_____________ Language(s) Spoken Education Education Information Name and Location of School Course of Study and Years Completed Diploma and Date High School Business, Trade, Technical College Graduate 1 215 West White Horse Pike Berlin, NJ 08009 List in Order of Employment Starting with Present Employer Employer: Dates Employed From Work Performed: To Address: Telephone Number(s): Job Title: Hourly Rate/Salary Starting / Final Supervisor: Reason for Leaving: May We Contact? Employer: Dates Employed From ______ Yes ______ No ______ Yes ______ No ______ Yes ______ No Work Performed: To Address: Telephone Number(s): Job Title: Hourly Rate/Salary Starting / Final Supervisor: Reason for Leaving: May We Contact? Employer: Dates Employed From Work Performed: To Address: Telephone Number(s): Job Title: Hourly Rate/Salary Starting / Final Supervisor: Reason for Leaving: May We Contact? Comments: Include explanation of any gaps in employment: __________________________________________________________________________________________ 2 215 West White Horse Pike Berlin, NJ 08009 Do you have any physical problems, conditions or limitations that prevent you from performing any work for which you are being considered? Yes / No If Yes, explain in detail:___________________________________________________________________ Have you ever been disciplined or fired? Yes____ No____ If Yes, explain? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Have you ever been convicted of a Crime? Yes____ No____ If Yes, explain? _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Have you ever been adjudged civilly or criminally liable for abuse of a developmentally disabled person? Yes____ No____ If Yes, explain? __________________________________________________________________________ _______________________________________________________________________________________ Have you ever submitted an application with us before? If Yes, give date:__________ Yes____ No____ Have you ever been employed with us before? If Yes, give date:__________ Yes____ No____ Do any of your friends or relatives, other than spouse, work here? Yes____ If Yes, state name, relationship: ____________________________________ No____ Date available for work: ______ /_____ /______ Availability Days (Please Check Off) What is your desired salary range? _________ Evenings (Please Check Off) Nights (Please Check Off) Sunday Monday Tuesday Wednesday Thursday Friday Saturday Max. # Of hrs you want to work per week _______ Minimum # of hrs. you want to work per week _______ 3 215 West White Horse Pike Berlin, NJ 08009 Managerial Experience: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Certification/Specialized Training Provided By Length of Training & Date(s) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please explain any additional qualifications, education or training: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Do you have certificates or written documentation, if any, for the above? ___Yes ___No Do you have any outside interest or hobbies that would be beneficial in performing the position in which you are seeking? Please List ___________________________________________________________________________________ Please list professional, trade, business or civic activities and offices held. _________________________ _____________________________________________________________________________________ I Authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts is cause for dismissal. Signature: Date: 4 215 West White Horse Pike Berlin, NJ 08009 APPLICATION STATEMENT I certify that the information provided on this Application for Employment and resume, if any, is true and complete. I understand that any misstatement, falsified information, significant omission or misrepresentation provided by me is grounds for refusal to hire, or if hired, immediate discharge from service, whenever it is discovered. I authorize The Arc of Camden County to investigate all statements and information contained in this application (and accompanying resume, if any), to make inquiries as may be necessary in arriving at an employment decision, and conduct a criminal history check, if applicable. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with my application. I understand that this application does not constitute an agreement or contract for employment for any specified period of definite duration. If employed by The Arc of Camden County, my employment will be for no set period of time and I am free to resign at any time with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. Nothing shall change the at-will status of my employment other than a written agreement signed by me expressly changing the employment at will status. Also, if employed, I will be required to abide by all the rules and regulations of The Arc of Camden County. I understand that if I am hired, I will be required to proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form with this regard. I further understand that all hiring commitments are conditional based upon satisfactorily meeting requirements through a pre-employment physical exam. A valid offer of employment can only be made by a letter signed by the Manager of Human Resources or the Executive Director. I certify that I have read, fully understand and accept all the terms of the foregoing Application Statement. Signature: Date: 5 215 West White Horse Pike Berlin, NJ 08009 INVITATION TO SELF-IDENTIFY Employee/Candidate Name: __________________________________________ Date: _______________________ Position Applied For: _____________________________________ Current Position: ________________________ As an employer with an Affirmative Action Obligation pursuant to Executive Order 11246, the Vietnam Era Veterans Readjustment Assistance Act, and the Rehabilitation Act, we must comply with government regulations regarding the collection of demographic information about our employees and about those individuals being considered for employment with our organization. We are required to invite individuals being considered for employment to self-identify as to gender, racial origin and ethnicity. Only if an offer of employment is extended, individuals are invited to selfidentify for consideration under our Vietnam Era Veteran’s and Disabled Affirmative Action Programs as well as to other veteran status. If you believe that you are covered by the above Acts, the Company invites you to self-identify for consideration under its Affirmative Action Programs. Provision of this information is voluntary and refusal to provide it will not subject the applicant or employee to adverse treatment. Further, if provided, the information will be kept confidential and used only in accordance with the Acts and regulations. I am: _____ Male _____ Female I am: _____ Black _____ Hispanic or Latino (White) _____ Asian _____ Hispanic or Latino (all other races) _____ White _____ Native Hawaiian or Other Pacific Island _____ American India/Alaskan Native White _____ I prefer not to disclose this information Definitions: Black or African American: (Not of Hispanic Origin) – All persons having origins in any of the Black racial groups of Africa. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. White: (Not of Hispanic Origin) – All persons having origins in any of the original people of Europe, North Africa, or the Middle East. American Indian or Alaskan Native: All persons having origins in any of the original people of North America and who maintain cultural identification through tribal affiliation or community recognition. Hispanic or Latino (white race only): A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, and of the White Race. Hispanic or Latino (all other races): A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, and of any other race other than White. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original people of Hawaii, Guam, Samoa or other Pacific Islands. 6