The Arc of High Point

Application for Employment

Please Print

Position(s) applied for _______________________________          Date of application  _____/_____/_____

Type of employment desired    ___ Full-time   ___ Part-time   ___ Temporary   ___ Seasonal

Name  _________________________________________________________________________________

            (Last)                                                          (First)                                                          (Middle)

Address  ________________________________________________________________________________

               (Street)                                                    (City)                                                    (State)              (Zip)

Telephone Number  ___________________________ Social Security Number _________/____/_________

Are you legally eligible for employment in the U.S.? Yes ___ No ___  (Proof of U.S. Citizenship or immigration status will be required upon employment)

Have you worked under any other name?  Yes ___ No ___ if yes, please list.  ________________________

(Required for verifying education, work records, and references)                 ___________________________

If required for the position for which you are applying, do you have a current, valid driver’s license?

 Yes ___ No ___ State ______.   Do you have car insurance?  Yes ____ No ____. 

Name of insurance company ________________________________________________________________

Address _________________________________________ Telephone # ____________________________

List any days or hours you are not available to work.  ____________________________________________

Minimum Salary Requirement $___________________ Date available for work  ____/_______/______

Educational Background

Circle Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12   GED  College 1 2 3 4  Graduate School  1 2 3 4

List specific courses, workshops, training or rotations you have had that are related to the position for which you are applying.  ________________________________________________________________________

____________________________________________________________________________________

Please list any work or volunteer experiences with people with intellectual and developmental disabilities

____________________________________________________________________________________

____________________________________________________________________________________

Summarize special skills and qualifications acquired from employment or other experience:

____________________________________________________________________________________

____________________________________________________________________________________

List any additional academic, professional, or volunteer references you would like to contacted in the event you are being considered for employment:

Name ____________________________________ Address  __________________________________

Phone ___________________________________ Relationship ________________________________

Name ____________________________________ Address  __________________________________

Phone ___________________________________ Relationship ________________________________

Name ____________________________________ Address  __________________________________

Phone ___________________________________ Relationship ________________________________

Employment History

List your last three (3) employers, starting with the most recent, including military experience.  Explain any gaps in employment in comments section below.

Comments (including explanation of any gaps in employment) _________________________________

____________________________________________________________________________________

If additional space is needed, please ask for a continuation sheet or use a sheet of paper.  All continuation Sheets and additional sheets of paper containing job history must be signed and dated by the Applicant.

PLEASE READ CAREFULLY AND SIGN BELOW

In making an application for employment with The Arc of High Point (Arc/HP), I understand and acknowledge the following: 

1. The information given by me on this application is true in all respects, and I have not failed to disclose information, which Arc/HP could consider relevant to its hiring decision.  I understand that I may be refused employment, or, if employed, terminated, if I give false or misleading information on my application or during the interview process.

2. Arc/HP has my expressed authorization to thoroughly investigate my work, or other related matters, as may be necessary in arriving at an employment decision.  This investigation may include personal interviews with former employers, references, neighbors, friends and others with who I am acquainted.  Further, I hereby authorize every person or entity contacted by Arc/HP to make any disclosure requested by Arc/HP and release all records, including employment, medical and school records such as assessments of my job performance and ability.  Furthermore, I agree to hold harmless any and all persons and entities contacted by Arc/HP during the course of the investigation.

3. I understand that all applicants may be required to successfully complete a drug screen prior to job offer.              Further, if hired, I may be required to undergo a drug test for reasonable suspicion of being under the influence of drugs and/or alcohol.

4. I understand that Arc/HP reserves the right to require a medical examination of an employee at any time except as may be prohibited by State or Federal law.

5. I understand that, if employed, my employment is for no definite period of time, that I may terminate my employment at any time without cause, and the Arc/HP may terminate or modify the relationship at any time without notice and without cause.

6. Should I become employed with Arc/HP, I agree to conform to the rules and regulations of the agency and any modifications or amendments thereto.  Also, I will preserve in the strictest all information concerning the business of Arc/HP and both former and current patients.

I have read and understand the above and have had the opportunity to ask questions, which, if asked,     were satisfactorily answered.

Date:  _________________________ Signature:  ______________________________________________

                                                                                         Applicant Identification Sheet

 For Equal Opportunity/Affirmative Action Purposes Only

The Arc of High Point (Arc) prohibits discrimination based on race, sex, religion, color, natural origin, age or disability.  The information requested below will not be used in the employment process.  This data will be physically separated from the remainder of your job application before the application is considered for possible employment.  Its purpose is to see how well our recruitment efforts are reaching all segments of the population.  All responses are COMPLETELY VOLUNTARY by the applicant.  Failure to provide it will NOT subject you to any adverse treatment.

Position Applied For __________________________________ Date ________________

Name _______________________________________________ Social Security # ______/_____/______

         (First)                          (Middle)                   (Last)

Address ______________________________________________________________________________

              (Street)                                                           (City)                                 (State)                  (Zip)

Telephone (______)___________________________________(_______)________________________

                 (Home)                                                                        (Business)

Date of Birth _________/__________/_________           Sex   ____Male    ____ Female

 Ethnic Background                                                                                                           How Did You Learn of This Position

____  1.  White (Caucasian, Non-Hispanic)                                                                      (Check One)

____  2.  Black (Origins in any of the black racial groups)                          ____  The Arc/North Carolina Listing

____  3.  Hispanic (Mexican, Puerto Rican, Cuban, Central                      ____  Newspaper Name ______________________

                                  or South American, other Spanish origin                      ____  Employment Security Commission

                                   regardless of race)                                                            ____  County’s Listing

____  4.  Asian (Including Pacific Islander)                                                   ____  From a Friend

____  5.  American Indian (Including Alaskan Native)                               ____  Other _______________________________

 Reservist/Veteran Information

Are you a reservist?  ____ Yes   ____ No

If yes, please indicate Branch of Service

______________________________

Are you a veteran?   ____ Yes   ____ No

 AUTHORIZATION

FOR RELEASE OF CONSUMER INFORMATION

I hereby authorize and request any former employer, school, police department, financial institution, or other persons having personal knowledge about me, to furnish FIRST ADVANTAGE CORPORATION and/or State Bureau of Investigations (SBI) with any and all information in their possession regarding me in connection with an application for employment.  I understand that investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports.  These reports will include information as to my character, work habits, performance and experience along with reason for termination from previous employers.  Further, I understand FIRST ADVANTAGE CORPORATION and/or State Bureau of Investigations (SBI) will be requesting information from various federal, state, and other agencies which maintain records concerning my past activities relating to my driving, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies.

I am willing that a photocopy of this authorization be accepted with the same authority as the original.  I understand this authorization is to be part of the written employment application, which I sign.

Print Full Name __________________________­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Social Security Number ____________________________ Date of Birth___________________________

(Date of birth is being requested in order to obtain accurate retrieval of records)

Current Address ________________________________________________________________________

City/State/Zip Code ______________________________________________________________________

Have you lived in North Carolina for the past five consecutive years?___________

If not, what other states have you resided in during the past five years?___________________________ _______________________________________________________________________________________

DRIVER’S LICENSE NUMBER _______________________STATE _________

APPLICANT’S SIGNATURE ________________________________________

DATE_______________________          

 Driver Privacy Protection Act Authorization

To Disclose Personal Information (DL-DPPA-2)

I understand that personal information contained in my Motor Vehicle records is protected by federal Driver Privacy Protection Act and N.C. General Statutes 20-43.1.  I hereby authorize that the personal information in my file may be released to the following person: 

Person to receive information:  The Arc of High Point, Inc.            

(please print clearly)

Your signature:__________________________________________________________

Your full name as it appears on your license (print clearly):

______________________________________________________________________

Your Driver License/ID Number: ______________________________________

Date:  ______________________________

DL-DPPA-2, v.1                                   9-13-97

The Arc of High Point

Applicant Drug and Alcohol

 Consent Agreement

 As a prerequisite to employment, I hereby agree to allow MedCentral to collect urine samples from me to determine the presence of drugs or alcohol in my body.  Further, I give my consent to the release of my test results to authorized The Arc of High Point management for appropriate review.

I understand that the results of the drug/alcohol test of my urine, if positive, will remove me from consideration for employment.  I also understand that if I refuse to consent, I will be removed from further consideration for employment.

Further, I understand that, if employed by The Arc of High Point, I must abide by the terms of The Arc of High Point Drug and Alcohol Policy and may be required to submit to testing for the presence of drugs or alcohol for reasons stated in The Arc of High Point policy.  I understand that submission to such testing is a condition of employment with The Arc of High Point and disciplinary action, up to and including discharge may result for violating The Arc of High Point Drug and Alcohol Policy.

I herby consent to the administration of the drug and alcohol test and to the terms and conditions of the Consent Agreement.

____________________________                            _____________________

Applicant’s Signature                                                 Date

Social Security No.  ____________                          

____________________________                            _____________________

Witness’s Signature                                                    Date

I hereby refuse the drug and alcohol detection urine test.

____________________________                            _____________________

Applicant’s Signature                                                 Date

Social Security No.  ____________                          

____________________________                            _____________________

Witness’s Signature                                                    Date