Easter Seals Arc

Application for Employment

PERSONAL DATA

Name

Address, City, State, Zip

Home Phone() Cell Phone Number () Work Phone Number ()

Social Security Number Driver’s License State

Have you previously been employed here? No Yes If yes, when position / Position desired:
1st choice
Hours per week
2nd choice
Hours per week
Have you previously applied here? No Yes
If yes, when? / If you want full time work but only part time is available, would you consider a part-time position?
Yes No
Do you know anyone currently employed by us? No Yes If yes, who and relationship / Are you age 18 or older?
Yes No

EDUCATION

MAJOR/ DEGREE or SCHOOL NAME MINOR DIPLOMA REC’D
GRADUATE
COLLEGE
BUSINESS,
TRADE, OR
TECHNICAL
HIGH SCHOOL XXXXXX

EMPLOYMENT HISTORY

Please give accurate, complete full and part time employment information. Start with you present or most recent employer.

EmployerTelephone()

Address Dates employed

Supervisor Salary/Hourly Rate

Position Held Reason for leaving

Type of work

Employer Telephone ()

Address Dates employed

Supervisor Salary/Hourly Rate

Position Held Reason for leaving

Type of work

Employer Telephone ()

Address Dates employed

Supervisor Salary/Hourly Rate

Position Held Reason for leaving

Type of work

Employer Telephone ()

Address Dates employed

Supervisor Salary/Hourly Rate

Position Held Reason for leaving

Type of work

Explain any gaps in your employment, other thanthose due to personal illness, injury or disability.

Have you ever been fired or asked to resign from a job? Yes No

If yes, please explain:

______

We may contact the employers listed above unless you indicate those you do not want us to contact.

Please do not contact the following employer(s)

Reason(s)

Special Training or Skills: Languages, machine operation, etc. that would be of benefit in the job for which you are applying.

Note: Answering “yes” to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Have you ever pleaded “guilty” or “no contest” to, or been convicted of a crime? YesNo

If yes, please provide date(s) and details:

Please tell us why you would like to work for Easter Seals Arc and what contributions and/or qualifications you have which would help us meet our mission - “creating solutions…changing lives.”

Drug Screen

I understand that potential employees will be required to submit to a pre-employment drug screen. The drug screen must be completed within 3 days of request. If the results of the drug screen are too diluted, I understand that I will be eliminated from consideration for employment, unless I am able to provide medical documentation to justify why the specimen may have been too diluted. This documentation must be provided to Human Resources within 3 days of receiving the results of my drug screen. If medical documentation is produced within the allowable time period, and a second drug screen is required, I understand that the second drug screen would be at my own expense.

Applicant Signature: Date

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misinterpretations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

If hired, I agree to conform to the Company’s rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or my Company’s option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this application remains current for only one year. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

I also understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws.

This Company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.

Applicant Signature: Date

REFERRAL SOURCE: Please check the appropriate category and list the source

Walk-in______ School______

Employee______Job Fair______

Advertisement______Staffing agency______

Company’s website______Government Employment Agency______

Other internet______ Other______

Are you related to an employee or Board Member of Easter Seals Arc of Northeast Indiana?

Yes______No______

If you answered yes, please list the names of your relatives

______

______

______

______

______

______

Applicant SignatureDate

*Please scroll down to the next page.

Affirmative Action Voluntary Information

Completion of information below is voluntary.

NAME:______

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application. In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide information will not subject you to any adverse personnel decisions or actions. Your cooperation is appreciated. Please be advised that this survey is not part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

Referral Source please check one of the following:

Walk-In Government Employment Agency Relative

Employee Private Employment Agency School

Advertisement – Source/other

Name of person who referred you (if applicable):

APPLICANT INFORMATION:

Name:

LAST, FIRST, MIDDLE

Address:

STREET, CITY, STATE, ZIP

Telephone Number:() Female Male

Please check one of the following Equal Opportunity Identification Groups:

White (not of Hispanic Origin)

Black or African American

Hispanic (all races)

Asian/Pacific Islander

American Indian/Alaskan Native

Multi-race

FHR-035Approved by: Sue KlugRevision 4/14/10

AFFIRMATIVE ACTION VETERAN STATUS VOLUNTARY INFORMATION

Completion of information below is voluntary

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, military/veteran status, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. The information will be used and kept confidential in accordance with the Vietnam-Era Veterans’ Readjustment Assistance Act of 1974, as amended, and all other applicable laws and regulations.

APPLICANT NAME: Date

APPLICANT SIGNATURE:

Iam a Special Disabled Veteran.

I am a disabled Veteran.

I am a Vietnam Era Veteran.

I am a veteran who was discharged or released from active duty with the U.S. Armed Forces within the past three years

I am a veteran who was discharged or released from active duty with the U.S. Armed Forces within the past year.

Other Protected Veteran

I am an Armed Forces Service Medal Veteran

I would like to be included under the company’s affirmative action program (if applicable pertaining to veterans of the U.S.

Armed Forces. (Note that you may make this request at this time and/or any time in the future.

None of the above applies to me (If you checked this box it is not necessary to complete the rest of this form).

EMPLOYER: Please indicate whether you are inviting applicants to participate in your company’s affirmative action program benefiting disabled veterans.

Yes The Company invites its applicants to provide information (on a voluntary basis) regarding their status as a “disabled veteran” for inclusion in the company’s affirmative action program. (check this box only if the company is actually undertaking affirmative action for disabled veterans at the application stage (pre-offer) or is otherwise authorized to collect this data to comply with federal, state or local affirmative action obligations pertaining to disabled veterans. Otherwise, it is advisable to wait until a conditional offer of employment has been extended before inquiring about disability status.

APPLICANT: If the company has checked “Yes” to the question above, you are invited to provide additional information regarding your status as a “disabled veteran”. The law defines disabled veteran as: (a) a veteran of the U.S. Armed Forces who is entitled to compensation (or who but for the receipt of military retired pay would ge entitled to compensation) under laws administered by the Secretary of Labor, or (b) a person who was discharged or released from active duty beause of a service-connected disability.

If you are a disabled veteran, please indicate whether you would like to be included under the company’s affirmative action program for disabled veterans. You may elect to be included at this time or any time in the future.

Yes, I would like to be included under the company’s affirmative action program for disabled veterans. (If a job offer is extended, you may be asked to provide more information to assist with placement and accommodation issues.)

No. At this time, I would not like to be included in the company’s affirmative action for disabled veterans.

FHR-036 Approved by: Sue KlugRevision: 4/30/09

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005
Expires 1/31/2017

Page 1 of 8

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.[i] To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
/
  • Autism
/
  • Bipolar disorder
/
  • Post-traumatic stress disorder (PTSD)

  • Deafness
/
  • Cerebral palsy
/
  • Major depression
/
  • Obsessive compulsive disorder

  • Cancer
/
  • HIV/AIDS
/
  • Multiple sclerosis (MS)
/
  • Impairments requiring the use of a wheelchair

  • Diabetes
  • Epilepsy
/
  • Schizophrenia
  • Muscular dystrophy
/
  • Missing limbs or partially missing limbs
/
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

☐ / YES, I HAVE A DISABILITY (or previously had a disability)
☐ / NO, I DON’T HAVE A DISABILITY
☐ / I DON’T WISH TO ANSWER

______

Your Name Today’s Date

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005
Expires 1/31/2017

Page 2 of 8

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

[i]Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.