Employment Application

Step 1 of 4

Position applied for *

Date *

Name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Will you have a vehicle available to carry out duties? *

Do you have a valid driver's license? *

Date available for employment *

Education History

High School

Name *

Address *

Address Line 1

City

State

Zip Code

Start Date *

End Date *

College

Name

Address

Address Line 1

City

State

Zip Code

Start Date

End Date

Major

College #2

Name

Address

Address Line 1

City

State

Zip Code

Start Date

End Date

Major

Other Education

Name

Address

Address Line 1

City

State

Zip Code

Start Date

End Date

Other Education #2

Name

Address

Address Line 1

City

State

Zip Code

Start Date

End Date

Have you ever been convicted of any violation of the law other than minor traffic violations? If so, explain. *

Employment History

Company #1

Company Name

Start Date

End Date

Position

Supervisor Name

First

Last

Supervisor Phone

Reason for leaving

Can we contact?

Company #2

Company Name

Start Date

End Date

Position

Supervisor Name

First

Last

Supervisor Phone

Reason for leaving

Can we contact?

Company #3

Company Name

Start Date

End Date

Position

Supervisor Name

First

Last

Supervisor Phone

Reason for leaving

Can we contact?

Explain any gaps in your employment history *

Have you ever been dismissed, suspended or allowed to resign for cause? If so, explain. *

References

Reference #1

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Phone

Reference #2

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Phone

Reference #3

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Phone

I hereby affirm that the information above is true and correct. I understand that if employed, falsified information on this application shall be considered sufficient cause for dismissal. I consent to the release of any and all information as may be requested by The Arc of Cass County of the individuals and organizations listed in this application with the exception of those marked "no" under Employment History. I further understand that in the event of employment, I expect to conform to policies and procedures of The Arc of Cass County. By signing below, I am consenting to the review of federal and state criminal history record systems and civil child abuse and neglect registries.

Signature *

Date *

Position applied for

Date

Name

Address

Telephone

Will you have a vehicle available to carry out duties?

Do you have a valid driver's license?

Date available for employment

Salary acceptable

High School

Name & Location

# Years Attended

Dates

College

Name & Location

# Years Attended

Degree & Dates

Major

Name & Location

# Years Attended

Degree & Dates

Major

Other

Name & Location

# Years Attended

Degree & Dates

Major

Name & Location

# Years Attended

Degree & Dates

Major

Have you ever been convicted of any violation of the law other than minor traffic violations? If so, explain.

Company 1

Company

Dates

Position

Ending Salary

Supervisor & Phone #

Reason for leaving

Can we contact?

Company 2

Company

Dates

Position

Ending Salary

Supervisor & Phone #

Reason for leaving

Can we contact?

Company 3

Company

Dates

Position

Ending Salary

Supervisor & Phone #

Reason for leaving

Can we contact?

Explain any gaps in your employment history

Have you ever been dismissed, suspended or allowed to resign for cause? If so, explain.

References

Name

Address

Telephone

Name

Address

Telephone

Name

Address

Telephone

I hereby affirm that the information above is true and correct. I understand that if employed, falsified information on this application shall be considered sufficient cause for dismissal. I consent to the release of any and all information as may be requested by The Arc of Cass County of the individuals and organizations listed in this application with the exception of those marked "no" undder Employment History.
I further understand that in the event of employment, I expect to conform to policies and procedures of The Arc of Cass County.
By signing below, I am consenting to the review of federal and state criminal history record systems and civil child abuse and neglect registries.

Signature of applicant

Date