A Community Service Provider Dedicated to Providing Self-Directed

Carobell, Inc.

A Community Service Provider dedicated to providing self-directed

supports for individuals with intellectual developmental disabilities,

empowering the to reach their fullest potential

EMPLOYMENT APPLICATION

HOW TO APPLY:

Below is our Employment Application in Word format. The application has been formatted so information can be typed directly on the form. Make sure to include information for 3 references on the forms attached to the application.

Options for filling out and submitting application:

You may print out this application, fill it out and mail it in or drop it by our Hubert office;
You canfill it out online and save it to your documents; it can then be emailed as an attachment to our Human Resources department; OR
It can be faxed to our Human Resources department secure fax number 910.326.0030.

Resumés may be submitted (in person, by mail, by email, or by fax) to the Human Resources Department, but the formal application below is still required.

(If you do not have the capability to print out this application you can stop by our Administrative Office at 198 Cinnamon Drive in Hubert, NC and pick one up and fill it out and turn it in there.)

EMPLOYMENT APPLICATION

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status.

Position Applying For: / Date:
Name:

LastFirstMI Other Name(s) Used for Employment

Address:

StreetAddressCityState Zip Code

Daytime Phone #: / Driver’s License #:
Alternate Phone #:
Were you previously employed by us? / No / Yes / If yes, when?
Have you previously applied here? / No / Yes / If yes, when?
Are you related to anyone employed here? / No / Yes / Name:
If you are presently employed, may we contact your employer? / No / Yes
Are you legally eligible for employment in the USA? / No / Yes / State Age if under 18:

EDUCATIONAL DATA

School Name / City / State / Diploma/Area of Degree
High School:
College:
Voc/Tech:
GED:
Do you hold a certification or licensure in North Carolina? / No / Yes
If yes, list #: / Type:
Certain positions within our organization are subject to short notice for hours of duty. Would transportation be
available to you at all times? / No / Yes
Certain positions within our organization have the requirement of availability for all three shifts as well as Saturday
and Sunday. Would this be a problem for you? / No / Yes / If yes, why?
Date Available to Work: / What shifts are you available to work? / 7-3 / 3-11 / 11-7
I am looking for: / Full Time / Part Time / Either

List training, experiences, skills or qualifications which you feel would especially fit you for work with individuals who havedevelopmental disability diagnoses and multiple handicaps:

Certain positions at Carobell require employees to lift up to 40 pounds without assistance. Can you perform
this task? / No / Yes
Certain positions at Carobell require employees to lift over 40 pounds with assistance. Can you perform this
task? / No / Yes

Have you ever been convicted of a crime? (A conviction does not mean you cannot be hired. The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying.)

No / Yes / If yes, explain:

EMPLOYMENT RECORD

List all past employment, starting with most recent employer. Use additional sheet if necessary.

Name and Address
Of Previous Employer / Type of Work / Dates Employed / Reason for
Leaving
From / To

List places of residence for the past five (5) years starting with current residence:

Length of Time / Street Address / City / State / County

State briefly why you want to work at Carobell:

AUTHORIZATION AND RELEASE OF INFORMATION

PLEASE READ CAREFULLY BEFORE SIGNING BELOW

I certify that all statements made in this application are true, complete and correct to the best of my knowledge and belief and are made in good faith. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal.

I hereby authorize Carobell, Inc. to make any investigation concerning my past employment history, driving record, personal references, criminal record and other statements contained in this application.

Employees of Carobell are hired “at-will.” An agreement to hire does not constitute a legal contract.

Our standards require a criminal background check on all prospective employees. Employment is contingent upon satisfactory completion of employment check, screening tests (including a drug screen) and other hiring requirements.

I hereby acknowledge that I have been informed that as of January 1, 2012 all Carobell locations, campuses and vehicles will be smoke free and that, dependent upon staffing levels and client needs, I may not be able to smoke during my entire work shift.

Signature of ApplicantDate

Rev: 9/5/12

CAROBELL, INC. IS AN EQUAL OPPORTUNITY EMPLOYER

Carobell, Inc.

Empowering Individuals to Reach

Their Fullest Potential

198 Cinnamon Drive – Hubert, NC28539–910-326-7600

Email:

Secure FAX: 910-326-0030

REFERENCE NAME
Street Address or P. O. Box #
City, State, Zip Code
Work Phone Number
FAX Number
APPLICANT: In the space provided at the left, please enter the name and address of a FORMER EMPLOYER or SUPERVISOR.

I have applied for employment at Carobell, Inc. I have read the material and questions below. I authorize you to render the opinions and form the judgments and provide them with the information requested. I hereby release you and/or your company from all liability whatsoever as a result of the completion of this reference.

Social Security Number / Signature of Applicant / Date

(APPLICANT: PLEASE DO NOT ENTER INFORMATION BELOW THIS LINE.)

******************************************************************************************************************************************

has listed you as a BUSINESS reference. Please complete the following section.

Information regarding the applicant will be treated as confidential.

WORK REFERENCE

Dates Employed: / From / To / Position Held:
Eligible for Rehire? / No / Yes / Why?
Above Average / Average / Below Average / Unsatisfactory
Job Knowledge
Quality of Work
Cooperation
Ability to Get Along With Others
Initiative
Attendance
Attitude
Dependability
Personal Appearance
Length of time you have known applicant? / In what capacity?
Would you recommend this person for a position at Carobell, Inc.? / NO / YES / Explain why?
Date / Signature

CAROBELL, INC. IS AN EQUAL OPPORTUNITY EMPLOYER

Carobell, Inc.

Empowering Individuals to Reach

Their Fullest Potential

198 Cinnamon Drive – Hubert, NC28539–910-326-7600

Email:

Secure FAX: 910-326-0030

Social Security Number / Signature of Applicant / Date

(APPLICANT: PLEASE DO NOT ENTER INFORMATION BELOW THIS LINE.)

******************************************************************************************************************************************

has listed you as a BUSINESS reference. Please complete the following section.

Information regarding the applicant will be treated as confidential.

WORK REFERENCE

CAROBELL, INC. IS AN EQUAL OPPORTUNITY EMPLOYER

Carobell, Inc.

Empowering Individuals to Reach

Their Fullest Potential

198 Cinnamon Drive – Hubert, NC28539–910-326-7600

Email:

Secure FAX: 910-326-0030

REFERENCE NAME
Street Address or P. O. Box #
City, State, Zip Code
Work Phone Number
FAX Number
APPLICANT: In the space provided at the left, please enter the name and address of a FORMER EMPLOYER or SUPERVISOR.

Social Security Number / Signature of Applicant / Date

(APPLICANT: PLEASE DO NOT ENTER INFORMATION BELOW THIS LINE.)

******************************************************************************************************************************************

has listed you as a BUSINESS reference. Please complete the following section.

Information regarding the applicant will be treated as confidential.

WORK REFERENCE