Autauga/Western Elmore Arc · (334) 365-4054

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Emploment Application

Employment Application

Please complete all fields, if incomplete your application may not be accepted. If you have no information to enter, put N/A.

First, middle Initital and last Name

Today's date:

Are you 21 years old or older?

Yes

No

Address

City, State

Phone number

Alternate phone number

Email

Free Text

_________________________________________

Position desired:

Day Program CSP

Residential DSP

Other

If selected other, which position?

Availability

Full Time

Part Time

Sub

Temporary

Date available to begin:

Free Text

1st SHIFT: 7am-3pm

2nd SHIFT: 3pm-11pm

3rd SHIFT: 11pm-7am

Monday availability

1st Shift

2nd Shift

3rd Shift

Not available

Tuesday availability

1st shift

2nd shift

3rd shift

Not available

Wednesday availability

1st shift

2nd shift

3rd shift

Not available

Thursday availability

1st shift

2nd shift

3rd shift

Not available

Friday availability

1st shift

2nd shift

3rd shift

Not available

Saturday Availability

1st shift

2nd shift

3rd shift

Not available

Sunday Availability

1st shift

2nd shif

3rd shift

Not available

Have you ever submitted an application to this agency before?

Yes

No

If yes, when?

Have you ever been employed by this agency before?

Yes

No

If yes, when?

Have you ever been convicted/pled guilty to, pled no contest to, or admitted to any crime, including but not limited to, sex-related or child abuse-related offenses?

Yes

No

I certify that I am a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States.

Yes

No

Do you have a Driver's License?

Yes

No

If yes, issued in what state?

Have you had any accidents during the past 3 years?

Yes

No

If yes, how many?

Have you had any moving violations during the past 3 years?

Yes

No

If yes, how many?

Free Text

__________________________________________

High School Attended

Years Attended

Location of High School (city,state)

Did you receive a diploma?

Yes

No

Did you attend more than one high school?

Yes

No

If yes, please list the school, it's location and years attended.

College or Trade School Attended

Location (city, state)

Did you receive a major degree or diploma?

Yes

No

N/A

College or Trade School Attended

Location of college or trade school (city, state)

Did you receive a major degree or diploma?

Yes

No

N/A

Free Text

__________________________________________

Free Text

Do you have any certificates or certifications?

Name of certificatation/certificate?

Date completed

Expiration date, if applicable

Name of certificatation/certificate?

Date completed

Expiration Date - if applicable

Name of certificatation/certificate?

Date completed

Expiration Date - if applicable

Free Text

_________________________________________

Please list work experience beginning with your most recent job held.

MOST recent employer

Name of supervisor

Employer address

Employer phone number

Start date

End date

Job title

List the positions held, duties performed, and major responsibilities.

Reason for leaving?

May we contact this employer?

Yes

No

Previous Employer Name #1

Name of Supervisor

Employer Address

Employer phone number

Start date

End date

List the positions held, duties performed, and major responsibilities.

Reason for leaving?

May we contact this employer?

Yes

No

Previous employer name #2

Supervisor name

Employer phone number

Employer address

Start date

End date

Job title

List the positions held, duties performed and major responsibilities.

Reason for leaving?

May we contact this employer?

Yes

No

Free Text

__________________________________________

Please provide 4 personal references. These references should not include former employers or family. Please obtain permission from these persons and inform them they may receive a call about you. By providing these reference, you authorize AWE/Arc to contact these persons prior to an interview.

Yes, I understand.

First name, last name

Phone number

Circumstances of acquaintance

First name, last name

Phone number

Circumstances of acquaintance

First name, last name

Phone number

Circumstances of acquaintance

First name, last name

Phone number

Circumstances of acquaintance

Free Text

__________________________________________

Free Text

With my electronic submission of this application, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that, should this application contain false or misleading information, my application may be rejected or my employment with this agency terminated should I be hired. I understand that this application does not constitute a contract of employment.

By checking this box, I acknowledge that I have read and understand this statement.

Thank you for submitting.

We will get back to you as soon as possible.

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Phone: 334-365-4054
Email: jess.butrica@awearc.org
Address:
298 Jay Street
Prattville, AL 36066
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