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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
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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:
__________________________________________________________________________________________
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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 _______
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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:
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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:
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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.
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