2911 Cleveland Ave. Santa Rosa. Ca. 95403 Ph: 707-527-7032 Fax: 707-528-6858

EMPLOYMENT APPLICATION

Thank you for considering employment with Anova. This application is part of a total evaluation process and is not a guarantee of employment. Please answer all questions completely and accurately. All statements are subject to verification.

First Name: Middle Initial: Last Name:

Other Names Used (if any):

Address: City, State, Zip:

Primary Telephone: Secondary Telephone:

Position Applying For:

Date: eMail:

Due to the nature of our work, all hires are contingent upon a satisfactory DOJ fingerprint check. Have you ever been convicted of a criminal offense? Yes No not sure

If yes or not sure, please explain briefly:

If required for the job, do you possess a valid driver’s license? Yes No

State:Number:

If hired, would you have reliable means of transportation to and from work? Yes No Need to discuss

If hired, can you provide verification of your legal right to work in the United States? Yes No

Are you able to perform all of the required duties of the job for which you are applying (see job description) with or without reasonable accommodations? Yes No

If no, describe duties that cannot be performed:

Do you have relatives or friends that work at Anova or use our services? Yes No

Have you ever applied for employment with Anova? Yes No

Have you ever been employed by Anova in the past?Yes No

If yes, indicate position and date:

If an Anova employee referred you for employment, please indicate his/her name:

How did you learn of this employment opportunity?

Date Available:

Salary or Hourly Rate Desired: per hour annual per day (if contracted)

Type of Employment Desired: RegularTemporary Full-Time Part-Time

Are you willing to work overtime?Yes No

When are you available for work?

Weekdays All daysMondaysTuesdaysWednesdays Thursdays

FridaysSaturdaysSundays

Which types of special needs individuals have you worked with in the past?

Developmentally Disabled

Emotionally Disturbed

Mentally Ill

Autistic

Other: None

In what settings have you worked?

Regular Ed Classrooms

Special Ed Classrooms

Non-public Schools

Adult Day Programs

Residential Homes

Behavioral Service Agencies

Other:

Please indicate which age groups you have worked with and which age groups you prefer working with:

Age GroupExperiencePreference

Pre-K

Elementary

Middle School

High School

In which areas are you willing to work?

American Canyon

Berkeley

Cloverdale

Concord

Guerneville

Healdsburg

Napa

Occidental

Petaluma

Rohnert Park

San Rafael

Santa Rosa

Sebastopol

Sonoma

Vallejo

Windsor

Are you trained in crisis intervention (e.g. Pro-Act certified)? Yes NoName of training:

EDUCATION
School Level / Name and Location of School / Course of Study / Number of years completed / Did you
graduate? / Degree or
Diploma
High School / YN / Y N
College/University / Y N / Y N
Post Graduate / Y N / Y N
Business/Trade School / Y N / Y N
Notes re education in progress:
List any current credentials or licenses:
SKILLS - If Applicable for Position for Which You Are Applying
Foreign Languages (indicate proficiency to speak, read and write):
List applicable procedures and/or equipment you can operate that are related to the position.
Do you have any experience, training, qualifications or skills that you think make you especially suited for work at ANOVA (Explain)
EMPLOYMENT INFORMATION (Start with Current or Most Recent Employer)
1 / Company Name / Phone / From Mo./Yr. / To Mo./Yr.
Street Address / City / State / Zip / Starting Pay
$ / Ending Pay
$
Job Title / Days per year (for school based employees only):
Year round or Contracted for days / Reason for leaving
License or Credential Type
Supervisor Name and Phone Number / Duties: / May we contact this employer?
Y N
2 / Company Name / Phone / From Mo./Yr. / To Mo./Yr.
Street Address / City / State / Zip / Starting Pay
$ / Ending Pay
$
Job Title / Days per year (for school based employees only):
Year round or Contracted for days / Reason for leaving
License or Credential Type
Supervisor Name and Phone Number / Duties: / May we contact this employer?
Y N
3 / Company Name / Phone / From Mo./Yr. / To Mo./Yr.
Street Address / City / State / Zip / Starting Pay
$ / Ending Pay
$
Job Title / Days per year (for school based employees only):
Year round or Contracted for days / Reason for leaving
License or Credential Type
Supervisor Name and Phone Number / Duties: / May we contact this employer?
Y N
4 / Company Name / Phone / From Mo./Yr. / To Mo./Yr.
Street Address / City / State / Zip / Starting Pay
$ / Ending Pay
$
Job Title / Days per year (for school based employees only):
Year round or Contracted for days / Reason for leaving
License or Credential Type
Supervisor Name and Phone Number / Duties: / May we contact this employer?
Y N
ACKNOWLEDGMENT - Please read carefully, initial each paragraph, and sign below
Initial / I authorize any person, school, current employer (except as expressly noted), past employer(s), and organizations named in this application form (and accompanying resume or other documentation, if any) to provide Anova with relevant information and opinion, personal or otherwise, that may be useful in making a hiring decision. I understand that all employment offers are contingent upon Department of Justice and FBI Fingerprint clearance.
Initial / I understand that nothing contained in this application or in the interview process is intended to create a contract between Anova and myself for either employment or for the providing of any benefits. I agree that my employment, if hired, is at-will, meaning that either the Company or I am free to terminate my employment at any time, with or without notice, with or without cause.
Initial / I understand that all offers of employment are conditioned upon my providing proof of my identity and legal right to work in the United States, as well as recent (4 yrs) TB clearance and a copy of my high school diploma or college degree.
Initial / By clicking the submit button below, I hereby acknowledge that I have read the above statements and understand them. I certify that I, the undersigned applicant, have personally completed this application. I declare under penalty of perjury that the facts contained in the application (or any resume or other documents submitted) are true and complete to the best of my knowledge. I understand that any misrepresentations or omissions will disqualify me from further consideration for employment, and will be justification for my dismissal from employment, if discovered later.
Applicant Signature: / Date:

Anovais an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, age, disability or veteran’s status or any other characteristic protected by law.We assure you that your opportunity for employment with this Company depends solely on your qualifications. Thank you for completing this application form, and for your interest in Anova.

Revised 04/2015