New Employee Referral Bonus Program
Please read all instructions carefully and complete all sections of this application completely and accurately. Your application may be considered ineligible for review if information is omitted or inaccurate
Date of Application:
First Name:
Middle Name:
Last Name:
Social Security Number:
Address:
City:
State:
AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code:
Email Address:
Telephone Number:
If you have ever worked under a different name, please specify:
Position Applied For:
Days/Hours you are able to work?
Minimum salary expected?
Type of employment desired?
Are you able to work overtime if required?
If no, please explain:
How were you referred to the Arc?
Employee
Ad
Walk-in
Other
Please indicate the specific name of referral source:
When would you be available to work?
Have you ever filed an application with us before?
If yes, the date?
Have you ever been employed by us before?
If yes, the dates?
Have you ever been convicted of a crime?
If yes, please explain:
Have you ever been discharged or asked to resign from any employment?
If yes, please explain:
Are you at least 18 years of age or older?
Are you currently employed?
Are you legally eligible for employment in the United States?(proof of identity and employment eligibility will be required upon employment)
Have you been a resident of the Commonwealth of Pennsylvania for at least two years prior to the date of this application for employment?
The Arc considers applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status. The presence of a non-job related disability or any other legally protected status. Equal access to programs, services and emnployment is available to all persons. Those applicants requiruing reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.
Employment Experience
Please give accurate, complete full and part-time employment record. Start with your present or most recent employer. You must account for ALL time periods, including unemployment, self-employment, and US military service. You may also attach a resume, but this section must be completed entirely. Referring to attached resume is not acceptable.
Employer:
Address:
Telephone #:
Your Job Title:
Supervisor's Name & Title:
Reason for leaving?
Dates Employed:
from
Hourly Rate/Salary:
starting
Summarize your job duties:
Employer:
Address:
Telephone #:
Your Job Title:
Supervisor's Name & Title:
Reason for leaving?
Dates Employed:
from
Hourly Rate/Salary:
starting
Summarize your job duties:
Employer:
Address:
Telephone #:
Your Job Title:
Supervisor's Name & Title:
Reason for leaving?
Dates Employed:
from
Hourly Rate/Salary:
starting
Summarize your job duties:
Employer:
Address:
Telephone #:
Your Job Title:
Supervisor's Name & Title:
Reason for leaving?
Dates Employed:
from
Hourly Rate/Salary:
starting
Summarize your job duties:
We may contact the employers listed above unless you indicate those you do not want us to contact.
Please do not contact (employer name(s)):
Employer number(s):
Reason:
Comments -including any gaps in employment:
Education
High School
School Name & Address:
Course of Study:
No. of Years Completed:
Did you graduate?
Degree or Diploma Earned*
Associate's Degree
School Name & Address:
Course of Study:
No. of Years Completed:
Did you graduate?
Degree or Diploma Earned*
Bachelor's Degree
School Name & Address:
Course of Study:
No. of Years Completed:
Did you graduate?
Degree or Diploma Earned*
Master's Degree
School Name & Address:
Course of Study:
No. of Years Completed:
Did you graduate?
Degree or Diploma Earned*
Other (Vocational, technical, post-graduate, etc.)
School Name & Address:
Course of Study:
No. of Years Completed:
Did you graduate?
Degree or Diploma Earned*
*Proof of educational credentials may be required upon employment.
Describe any specialized training, certifications, skills, and extra-curricular activities.
Describe any job-related training received in the United States military.
Any additional information you feel may be helpful to us in considering your application.
Certain jobs require a valid state driver's license. Do you have one?
State:
AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Driver's License #:
Expiration Date:
Professional References
Please list three individuals not related to you and who can attest to the quality of your work history.
Name:
Address:
Telephone #:
Association:
Years known:
Name:
Address:
Telephone #:
Association:
Years known:
Name:
Address:
Telephone #:
Association:
Years known:
Applicant's Statement Please read carefully:
I hereby declare that the above statements are true, correct, and complete to the best of my knowledge.
In the event of employment, I understand that any misrepresentation or omission of fact made in my application or interview(s) will be just and due causes for my discharge from employment. I understand, also, that I am required to abide by all rules and policies of Arc of Northeastern Pennsylvania.
Further, I understand and acknowledge that any employment relationship with The Arc is “at will,” which means that, if I am employed by the agency, my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the agency or myself.
In consideration of Arc of Northeastern Pennsylvania’s evaluation of my suitability for employment, I hereby authorize the agency to perform all checks of my credentials as allowed by law. This authorization shall include my former employer(s) to furnish the Arc with whatever information they may have regarding my employment, including my reason(s) for leaving. I am signing this waiver voluntarily, and request that my former employer(s) respond to reference inquiries conducted by The Arc with full and complete information. Since this reference is an important part of my application for employment with Arc of Northeastern Pennsylvania, I therefor waive and release The Arc and my former employer(s) from any and all claims or causes of action in law or equity, including, but not limited to, defamation of character or invasion of privacy, which might arise from responding to this reference check.
I acknowledge that The Arc has made no representations of any kind as to whether employment will be offered at the conclusion of the investigation.
I understand that, as part of Arc of Northeastern Pennsylvania’s pre-employment procedures, any offer of employment is conditioned upon me submitting to and passing a pre-employment medical examination, including Tuberculin testing and controlled substance screening. Failure to comply with this requirement or having an unsatisfactory result will result in ineligibility for employment at The Arc.
I further understand that if I voluntarily terminate my employment with The Arc, for whatever reason, prior to the conclusion of my probationary period, I will maintain liability to The Arc for the cost of my pre-employment medical examination, including Tuberculin testing and controlled substance screening. If the aforementioned should occur, these costs will be deducted from my final paycheck. I also acknowledge that if the aforementioned should occur before i earn a paycheck, I shall still maintain libility to The Arc for these costs. In this last instance, I understand that The Arc may take whatever legal action it deems appropriate in order to recover these costs.
I understand the above conditions cannot be altered or amended, except in writing signed by the Executive Director.
Applicants Signature
Date:
Thank you for your interest in employment opportunities with the Arc.
