Applicant’s Last, First Name:

Employment Application

Thank you for your interest in Wake Research Associates (WRA, LLC). It is our policy to hire the best-qualified individual(s) available. Although everyone who applies cannot be hired, your application, if completed properly, will be given every consideration. These directions, and the authorization included for signature, are attached to and are intended to be a part of the application form. Wake Research Associates is an Equal Opportunity Employer.

Important: Please read and comply with the following before completing the Employment Application form.

  1. Incomplete Applications will not be accepted.
  2. To submit on-line, type your initials/full name/date in the signature areas, andpleaseinclude “last name” & “position applying for” when the file is uploaded.
  3. Give complete information on your education and work history. “See resume” is not acceptable. It is permissible for an applicant to attach letters of recommendation, resumes and related materials to the application however; resumes are NOT accepted in lieu of applications and may not be considered unless submitted with a completed application form.
  4. List separately each job held and your duties for each position when you worked for one employer and held more than one position. Complete and specific information is desired. If a position was part-time, the number of hours per week must be entered as accurately as possible. Give complete information on the job duties performed in each held position held.
  5. Educational detail is required and adequate space is provided in the Education Section; for example, show major and type of degree received. If a Human Services degree is required for the position for which you are applying, you should submit a transcript copy that supports the Human Services classification. Official transcripts and certificates and/or licenses are required at hire.
  6. Review your application to ensure that all information is complete and accurate. Applications that are incomplete will prevent consideration for an interview/employment. You must sign/initial the application in the areas requested; typing in your initials/full name/date is acceptable for electronic submission.
  7. Application forms are accepted for vacant and posted positions only. A separate, current application form must be completed and submitted for each vacant position.
  8. All applicants are subject to the Drug and Alcohol Free Policies adopted by Wake Research Associates. Our company is committed to a drug and alcohol free environment to protect employees and the public by insuring that all of our employees are fit to perform their assigned duties. All applicants will be subject to a pre-employment drug screen, a criminal record check, social media screening and a motor vehicle report (driving record) is required if applicable for the position. An applicant shall be denied employment with Wake Research Associates if his/her drug test is positive and any applicant who refuses to consent to a drug test will be denied employment with Wake Research Associates.

**REQUIRED FIELDS **
Position Applying For:
Expected Salary:
Date Available:
Last Name / First / Middle / Date of Application
Other Names Used (Maiden or “AKA”):
Street Address (Number and Name) / County
City / State / ZIP / Home Telephone:
Cell Phone:
Email:
Immigration Reform & Control Act / Driver’s License Information
After employment, you will be required to submit verification of your legal right to work in the United States. Wake Research Associates employs only United States citizens or aliens who can provide proof of identity and work authorization within 3 working days of employment. Wake Research Associates participates in E-verify. / Does the position you are applying for require a driver’s license?
[] Yes [] No. If YES, you MUST provide the information below:
License # / State Issued / Class or Type / Expiration Date
(mm/dd/yyyy)
Please list any Clinical Licensure Information or Certifications / Number / State Issued / Type / Expiration Date
(mm/dd/yyyy)
JOB RELATED EDUCATION AND TRAINING
Name of School / School Address
(City & State) / Dates Attended / Type of Degree or Diploma Received / Major Subjects Studied
From / To
High School (Includes GED equivalency) / Mo / YYYY / Mo / YYYY / (N/A if not graduated) / General High School/GED
Colleges or Universities / Mo / YYYY / Mo / YYYY / (N/A if not graduated) / Major
Technical, Vocational, or Military Training / Mo / YYYY / Mo / YYYY / (N/A if not graduated) / Major
Describe job-related skills, knowledge, special training, or licenses you have pertaining to the position. Please identify skills using computer software such as Word, Excel, PowerPoint, Access, or other specialized computer software:
Check One
Yes No
  1. Are you now, or have you ever been, employed by Wake Research Associates? If YES, identify most recent employment dates, job title, department assigned, and/or reason for leaving in the “comments” section below.

  1. Do you have any relatives currently employed by Wake Research? If YES, list their name(s), position, title, department assigned, and their relationship to you in the “comments” section below.

  1. Were you ever discharged or forced to resign from employment due to misconduct or unsatisfactory services? If YES, explain in the “comments” section below. Prior discharges or forced resignations will not necessarily disqualify you from employment.

  1. Have you been convicted of a crime in the past 10 years, which has not been annulled, expunged, or sealed by the court?

  1. Are you currently or have you ever been under investigation by a government authority? (DEA, FDA, Medicare, etc.) OR Are you currently under ANY criminal investigation?

Comments (for any YES answer from above, give number and explain):
  1. Employment Record (Most Recent):

Starting with previous or most recent, list all previous employers. Include self-employment and summer and part-time jobs.
  1. Employer:
/ Type of Organization:
(Government Agency, etc.) / Position Held:
Street Address (number and name): / Supervisor’s Name & Title: / Did you supervise others?
YES [] or NO []
City: / County: / State: / Zip: / Supervisor’s Telephone number: / If YES, How many did you supervise?
Date Employed (Mo/Yr) / Date Separated
(Mo/Yr) / Starting Salary / Ending Salary / Reason for leaving:
$ / $
Per / Per
Full time / Years: / Months: / May we contact this employer? YES [] No[]
Part time / Years: / Months: / Part-Time Weekly Hours:
List Major duties in Order of Their Importance in the Job:
  1. Employment Record (Continue with employment history prior to #1):

Starting with previous or most recent, list all previous employers. Include self-employment and summer and part-time jobs.
  1. Employer:
/ Type of Organization:
(Government Agency, etc.) / Position Held:
Street Address (number and name): / Supervisor’s Name & Title: / Did you supervise others?
YES [] or NO []
City: / County: / State: / Zip: / Supervisor’s Telephone number: / If YES, How many did you supervise?
Date Employed (Mo/Yr) / Date Separated
(Mo/Yr) / Starting Salary / Ending Salary / Reason for leaving:
$ / $
Per / Per
Full time / Years: / Months: / May we contact this employer? YES [] No[]
Part time / Years: / Months: / Part-Time Weekly Hours:
List Major duties in Order of Their Importance in the Job:
  1. Employment Record (Continue with employment history prior to #2):

Starting with previous or most recent, list all previous employers. Include self-employment and summer and part-time jobs.
  1. Employer:
/ Type of Organization:
(Government Agency, etc.) / Position Held:
Street Address (number and name): / Supervisor’s Name & Title: / Did you supervise others?
YES [] or NO []
City: / County: / State: / Zip: / Supervisor’s Telephone number: / If YES, How many did you supervise?
Date Employed (Mo/Yr) / Date Separated
(Mo/Yr) / Starting Salary / Ending Salary / Reason for leaving:
$ / $
Per / Per
Full time / Years: / Months: / May we contact this employer? YES [] No[]
Part time / Years: / Months: / Part-Time Weekly Hours:
List Major duties in Order of Their Importance in the Job:
  1. Employment Record (Continue with employment history prior to #3):

Starting with previous or most recent, list all previous employers. Include self-employment and summer and part-time jobs.
  1. Employer:
/ Type of Organization:
(Government Agency, etc.) / Position Held:
Street Address (number and name): / Supervisor’s Name & Title: / Did you supervise others?
YES [] or NO []
City: / County: / State: / Zip: / Supervisor’s Telephone number: / If YES, How many did you supervise?
Date Employed (Mo/Yr) / Date Separated
(Mo/Yr) / Starting Salary / Ending Salary / Reason for leaving:
$ / $
Per / Per
Full time / Years: / Months: / May we contact this employer? YES [] No[]
Part time / Years: / Months: / Part-Time Weekly Hours:
List Major duties in Order of Their Importance in the Job:
Professional/Work References:
List two past supervisors and one person who are not related to you who would have knowledge of your qualifications for the position for which you are applying.
Name / Occupation, Title, Relationship / Address
(Street, City, State, Zip Code) / Phone No.
(Include Area Code)
If hired, I understand that I enter a three (3) month probationary period and I agree to conform to the policies, rules, regulations, direction and instructions of Wake Research Associates.
Initials: /
I hereby certify that I have given true, accurate and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigation of all statements made in this application and understand that false information or documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: G.S. 126-30, G.S. 14-122.1.) Additionally, I understand that, as a condition of employment, I may be required to complete a pre-employment drug screen and I will have to successfully complete, criminal background check, social media screening and a motor vehicle report (driving record) if applicable for the position.
Applicant’s Signature: / / Date:

1 | Page