Employment Application

We are an equal opportunity employer, dedicated to a policy of non-discrimination on any basis including race, color, religion, creed, national origin, age, veteran status, marital status, citizenship, disability, or any other characteristics protected under the law.

ALL SECTIONS MUST BE COMPLETED TO BE CONSIDERED FOR EMPLOYMENT

Position(s) Applied For

Salary Desired

Date of Application

First Name

Last Name

Physical Address

Apartment Number or P.O. Box

City

State

ZIP

Mailing address is the same as Physical address

Mailing Address

Physical Address

Apartment Number or P.O. Box

City/Town

State/Province

ZIP/Postal Code

Telephone Number

Email Address

Check “Yes” or “No”

Have you been convicted of a felony or misdemeanor?

Yes

(Convictions will not necessarily disqualify an applicant for employment. Each one is considered in relation to the position applied for and the seriousness/nature of the crime. A criminal background check will be initiated prior to employment.)

Please explain
year of conviction?

EMPLOYMENT EXPERIENCE

Provide the following information concerning each of your employers, starting with your present or most recent position within the last 10 years

ALL QUESTIONS MUST BE COMPLETED

ALL QUESTIONS MUST BE COMPLETED
Employer (Current or Most Recent) Job Title or Position Date Employed From Date Employed To Currently Employed Here Address City State Zip code Telephone Number Supervisor Hourly Rate/Salary Starting $ Hourly Rate/Salary Final $ Description of Duties Reason for Leaving May we contact this employer? Yes No Eligible for Rehire? Yes No Explain Why?

EMPLOYMENT EXPERIENCE CONTINUED

EMPLOYMENT EXPERIENCE CONTINUED
Employer (Next Previous) Job Title or Position Date Employed From Date Employed To Currently Employed Here Address City State Zip code Telephone Number Supervisor Hourly Rate/Salary Starting $ Hourly Rate/Salary Final $ Description of Duties Reason for Leaving May we contact this employer? Yes No Eligible for Rehire? Yes No Explain Why?

If there have been any gaps in your employment during the last 10 years, provide details in the space provided here:

List professional, trade, business or civic activities and office held. Describe any specialized training, apprenticeship, skills and extracurricular activities (excluding those which, by their name or character, indicate the race, color, religion, sex, age, national origin, marital status, ancestry or handicap).

Summarize special training skills (such as machines, typing, PC skills, etc.), which you feel may especially qualify you for working with our company.

EDUCATION

EDUCATION
Name of High School Address of High School Did you graduate high school or receive your completion of GED? Yes No An high school diploma/transcript or completion of GED is required for most positions, this may affect your eligibility for employment Did you attend college Yes No Name of College attended Course of Study Was a degree obtained? Yes No Degree name Did you graduate from this college? Yes No

Name of High School

Address of High School

Did you graduate high school or receive your completion of GED?

Yes

An high school diploma/transcript or completion of GED is required for most positions, this may affect your eligibility for employment

Did you attend college

Yes

Name of College attended

Course of Study

Was a degree obtained?

Yes

Degree name

Did you graduate from this college?

Yes

REFERENCES

List three people who are not related to you and who are not previous supervisors, who you have known for at least one year and who we may contact as additional references.

Reference #1

Reference #2

Reference #3

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application or in any interview is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by Arkansas Center for Independence (ACI). (Please note that all information is subject to verification).

I understand and agree that nothing contained in this application, or conveyed during my interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at-will” and without fixed term, and may be terminated at any time, with or without prior notice, at the option of either ACI or myself. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon ACI unless made in writing by the ACI Executive Director.

If I am offered employment, I agree to submit to a drug test before starting to work and to take a tuberculosis test, at ACI’s expense. If employed, I also agree to submit to a drug test at any time deemed appropriate by ACI and as permitted by applicable law. I consent to such tests, and I request that the results of the tests be disclosed to ACI, which ACI will keep confidential. I understand that my employment or continued employment, to the extent permissible by applicable law, is contingent upon satisfactory TB and drug tests.

I understand that employment is contingent upon my complying with the employment verification requirements of the Immigration Reform and Control Act.

I understand that I must complete Arkansas Adult Maltreatment and Child Maltreatment Central Registry and forms. I further understand that these forms will be submitted to the appropriate agency to provide documentation that my name does not appear on the statewide Central Registry. I understand that in order to assure due diligence, background checks will/may be conducted to check for criminal history, worker’s compensation claims, driving record and abuse/neglect history. Failure to meet theserequirements may lead to my rejection as an applicant for employment with ACI.

I certify that I have read, or have had read to me, items numbered 1, 2, 3, 4, 5 and 6 above. I understand the contents and hereby acknowledge receipt of this information.

Signature Date

Signature

Signature required in order to be considered for employment

RELEASE AND WAIVER WRITTEN REQUEST FOR REFERENCE

Arkansas Center for Independence conducts a thorough reference check on applicants prior to hiring. Review carefully the release form attached and complete only the section indicated, then sign in the space indicated for each employer to be contacted. If you have any questions or comments to make, do so prior to signing the release form.

I authorize the above company/business to furnish Arkansas Center for Independence with whatever information they may need regarding my employment, including the reasons for leaving your employ. I am signing this Release and Waiver voluntarily, and to request that you respond to this reference inquiry with full and complete information. Since this reference is an important part of my application for employment with ACI, I therefore waive and release you 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.

Signature date

Signature

Sign above

EMPLOYMENT EXPERIENCE

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