Street Address

City State Zip

Home Telephone Cell Phone

E-mail Address

Have you ever applied for employment with us? Yes No

If yes, Month and Year Location

Are you currently authorized to work in the United States? Yes No
(Proof of eligibility will be required at hire.)

Check which shift you will accept:
Day Evening Overnight Weekends
Specify Shift Hours

Check which employment status you will accept: Full-time Part-time Relief (No Benefits)

I am able to lift and transfer a minimum of 50 pounds: Yes No

Position Applied For

When are you available to start?

Education

Select highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12

If you did not complete high school. Do you have a high school equivalency diploma? Yes No

Select number of years of post high school education: 1 2 3 4 5 6 7

Name and Location of Institution(s) attended.

Dates Attended

Dates Attended

Dates Attended

Degree(s) received

Major or Specialty

CERTIFICATIONS:

First Aid CPR MAPS
Expiration dates for above certifications:

Do you have a current driver's license? Yes No

Driver's License #:

State: Expiration Date:

Have you had any accidents in the past 3 years? Yes No
How Many?

Have you had any moving violations in the past 3 years? Yes No
How Many?

Military

Did you serve in the armed forces of the United States or reserve components thereof, including the National Guard?
Yes No

Work Experience - 1

Name of Employer

Telephone

Street Address

City State Zip

Job Title

Dates of employment: From: To:

Job Responsibilities

Reason for Leaving

Immediate supervisor

Work Experience - 2

Name of Employer

Telephone

Street Address

City State Zip

Job Title

Dates of employment: From: To:

Job Responsibilities

Reason for Leaving

Immediate supervisor

Work Experience - 3

Name of Employer

Telephone

Street Address

City State Zip

Job Title

Dates of employment: From: To:

Job Responsibilities

Reason for Leaving

Immediate supervisor

Work Experience - 4

Name of Employer

Telephone

Street Address

City State Zip

Job Title

Dates of employment: From: To:

Job Responsibilities

Reason for Leaving

Immediate supervisor

References

List your last three supervisors as references below

Include: Name, Address, Telephone Number, Supervisor

Certification

I hereby certify that all entries are true and complete and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment with the Northeast Arc.  I understand that all information on this application is subject to verification and I consent to criminal histories background checks.  I also consent that you may contact references, former employers and educational institutions listed regarding this application and hereby release the Northeast Arc from any liability as a result of such contact.

Type your name here to agree to above

Date

If a Northeast Arc employee referred you, please let us know who: