APPLICATION FOR EMPLOYMENT
PLEASE COMPLETE ALL SECTIONS IN THEIR ENTIRETY!
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify the HUMAN RESOURCE DEPARTMENT.
SUPPORTIVE CONCEPTS FOR FAMILIES, INC. IS AN EQUAL OPPORTUNITY EMPLOYER

Position

Position(s) applied for

Date of Application: May 19, 2013

Referral Source

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Relative
Walk-In
Private Employment Agency
Employee Name:
Other

Personal Information

LAST NAME
FIRST NAME
MIDDLE NAME
ADDRESS:
CITY:
STATE:
ZIP:
EMAIL ADDRESS:
TELEPHONE NO.:
SOCIAL SECURITY NO.:
1. If necessary, best time to call you at home is:
2. May we contact you at work? Yes No
3. If yes, work number and best time to call: Work No.:
4. If you are under 18 and it is required,can you furnish a work permit? Yes No
5. If no, please explain:
Have you submitted an application here before? Yes No
7. If yes, give date(s):
8. Have you ever been employed here before? Yes No
9. If yes, give date(s):
Are you legally eligible for employment in this country? Yes No
11. Date available for work:
12. Type of employment desired Full-time Part-time Temporary Seasonal Educational Co-Op
13. Will you relocate if job required it? Yes No
14. Can you travel if job requires it? Yes No
15. Are you able to meet the attendance requirements of the position? Yes No
16. Will you work overtime if required? Yes No
17. If no, please explain:
18. Have you ever been bonded? Yes No
19. Have you ever been convicted of a crime? Yes No
If yes, please explain

Conviction will not necessarily be a bar to employment. Each instance and explanation will be considered in relation to the position for which you are applying.

20. Have you ever plead – guilty to a crime? Yes No
If yes, please explain
Drivers License Number No.:
State:
Expiration date:
Vehicle Insurance: Yes No

Employment History

Provide the following information for your past and current employers, assignments or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.

Employer 1

EMPLOYER:
TELEPHONE:
DATES EMPLOYED From (mm/dd/yyyy) To (mm/dd/yyyy)
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESP0NSIBILITIES ADDRESS
JOB TITLE:
HOURLY RATE/SALARY
STARTING $ PER HOUR ENDING $ PER HOUR
IMMEDIATE SUPERVISOR
MAY WE CONTACT FOR REFERENCE? YES NO LATER
REASON FOR LEAVING
COMMENTS

Employer 2 (Click to expand)

EMPLOYER:
TELEPHONE:
DATES EMPLOYED From (mm/dd/yyyy) To (mm/dd/yyyy)
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESP0NSIBILITIES ADDRESS
JOB TITLE:
HOURLY RATE/SALARY
STARTING $ PER HOUR ENDING $ PER HOUR
IMMEDIATE SUPERVISOR
MAY WE CONTACT FOR REFERENCE? YES NO LATER
REASON FOR LEAVING
COMMENTS

Employer 3 (Click to expand)

EMPLOYER:
TELEPHONE:
DATES EMPLOYED From (mm/dd/yyyy) To (mm/dd/yyyy)
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESP0NSIBILITIES ADDRESS
JOB TITLE:
HOURLY RATE/SALARY
STARTING $ PER HOUR ENDING $ PER HOUR
IMMEDIATE SUPERVISOR
MAY WE CONTACT FOR REFERENCE? YES NO LATER
REASON FOR LEAVING
COMMENTS

Employer 4 (Click to expand)

EMPLOYER:
TELEPHONE:
DATES EMPLOYED From (mm/dd/yyyy) To (mm/dd/yyyy)
SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESP0NSIBILITIES ADDRESS
JOB TITLE:
HOURLY RATE/SALARY
STARTING $ PER HOUR ENDING $ PER HOUR
IMMEDIATE SUPERVISOR
IMMEDIATE SUPERVISOR MAY WE CONTACT FOR REFERENCE? YES NO LATER
REASON FOR LEAVING
COMMENTS

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may qualify you for this position.

Educational Background

A. List last three (3) schools attended, location, and telephone number starting with most recent.
B. List number of years completed.
C. Indicate degree or diploma earned, if any.
D. Major Field of study.
E. Minor field of study (if applicable).

School 1

NAME OF SCHOOL:
ADDRESS
TELEPHONE NUMBER:
YEAR COMPLETED:
DEGREE/DIPLOMA:
MAJOR:
MINOR:

School 2 (Click to expand)

NAME OF SCHOOL:
ADDRESS
TELEPHONE NUMBER:
YEAR COMPLETED:
DEGREE/DIPLOMA:
MAJOR:
MINOR:

School 3 (Click to expand)

NAME OF SCHOOL:
ADDRESS
TELEPHONE NUMBER:
YEAR COMPLETED:
DEGREE/DIPLOMA:
MAJOR:
MINOR:

References

List name and telephone number of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three (3) school or personal references that are not related to you.

Reference 1

NAME and relationship
TELEPHONE NUMBER:
ALTERNATE TELEPHONE NUMBER:

Reference 2 (Click to expand)

NAME and relationship
TELEPHONE NUMBER:
ALTERNATE TELEPHONE NUMBER:

Reference 3 (Click to expand)

NAME and relationship
TELEPHONE NUMBER:
ALTERNATE TELEPHONE NUMBER:

Additional Information

List professional, trade, business, or civic associations and any offices held. Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.

ORGANIZATION


OFFICES HELD



List special accomplishments, publications, awards, etc. Exclude information, which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.

List any additional information you would like us to consider.

Please Read and Sign

I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer’s service, whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, educational institutions, criminal background checks, child abuse checks, and personal references, and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not lawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 180 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that if I receive an offer of employment it will be conditioned on successfully completing drug testing that I must undergo before starting work. I hereby agree to submit to drug testing and consent to allow Supportive Concepts and any person or entity it may designate to perform drug testing on me. I also agree that the results of the drug testing may be divulged to Supportive Concepts.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without causes and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specific period of definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent a warrant that I have read and fully understand the foregoing and seek employment under these conditions.

SIGNATURE OF APPLICANT:
DATE: May 19, 2013