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Name

Personal Information

Title

First Name *

Last Name *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Email Address *

Contact Number *

Alternate Contact Number

Agency, Work, and Hours Information

Position Applying For *

Work availability: *

Full-Time Part-Time Provisional

Date available to start work: *

Hours available to work (check all that apply)

Weekdays ONLY Weekends ONLY Weekdays AND/OR Weekends Day Hours (ex. 9am - 5pm) Afternoon/Evening Hours (ex. 3pm - 11pm) Night Hours (ex 11pm - 9am)

Name of High School *

Location *

Did you graduate or obtain GED? *

Yes

Are there any days/hours you would be unable/unwilling to work? *

Have you ever worked for BARC Developmental Services? *

Yes No

If yes, specify dates, title and reason for leaving:

How did you learn of our organization? *

Careerlink

Newspaper

Other

Walk In

Website

Referenced

Education

Name of College/University/other

Major/Minor:

Location:

Number of Years

Did you graduate?

Yes

Name of Graduate School:

Major/Minor:

Location:

Did you graduate?

Yes

Type of Degree/Diploma

Employment History/Relevant Information

Start with present or most recent employer. Include contractual and consulting arrangements as well as volunteer work.

Company Name 1 *

Mailing or Street Address *

City *

State *

Phone *

Name of Supervisor: *

Dates Employed (Month/Year) *

Weekly Pay (starting/ending) *

Number of hours worked per week: *

State your job title and describe work performed: *

Reason for leaving: *

May we contact this employer: *

Yes No

Company Name 2 *

Mailing or Street Address *

City *

State *

Phone *

Name of Supervisor: *

Dates Employed (Month/Year) *

Weekly Pay (starting/ending) *

Number of hours worked per week: *

State your job title and describe work performed: *

Reason for leaving: *

If no, please explain:

Company Name 3

City

State

Phone

Name of Supervisor:

Dates Employed (Month/Year)

Weekly Pay (starting/ending)

Number of hours worked per week:

State your job title and describe work performed:

Reason for leaving:

If no, please explain:

Weekly Pay (starting/ending)

Upload Resume

Upload Cover Letter

Driver Information

Do you have a valid driver's license? (*) *

Yes

License Number *

Expiration Date *

Number of citations in past three years *

State *

Experience (Number of years) *

Types of vehicles *

Is your driver's license currently suspended or pending suspension? *

Yes

Have your driving privileges ever been suspended or your license revoked? *

Yes

General Information

List any special skills, qualifications, or training you have related to this position *

Are you a veteran of the U.S. military services? *

Yes

Have you ever been convicted of any crime involving a felony and/or misdemeanor conviction including driving while intoxicated? *

Yes

Do you have the legal right to work in the United States? *

Yes

State other names under which you have worked or attended school

Are you at least 18 years old? *

Yes

PLEASE READ AND COMPLETE THE FOLLOWING STATEMENTS CAREFULLY (*)

I attest that I have never been disciplined or released from employment or contractual/consulting arrangement or had law enforcement investigation or court proceedings due to abuse or neglect of persons supported (clients or residents) or other disciplinary procedures except as noted below. Write "N/A" if not applicable.

EMPLOYER Or Affiliation Source

CONTACT NAME and PHONE NO.

TYPE OF DISCIPLINARY ACTION

TERMINATION DATE

I further attest that I have never been sanctioned or disciplined by any employer, contractor, consulting or affiliation source, staffing agency or professional organization to which I currently or previously was affiliated with except as noted below:

EMPLOYER Or Affiliation Source

CONTACT NAME and PHONE NO.

TYPE OF DISCIPLINARY ACTION

TERMINATION DATE

I affirm that the information provided on this application (and any accompanying resume or application materials) is true and complete to the best of my knowledge. I agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I understand and accept that employment with BARC Developmental Services is an at-will relationship, and that it may be terminated by BARC Developmental Services or by me at any time and for any reason, without cause or notice.

I understand that there is no guarantee of continued employment with BARC Developmental Services. I understand that any offer of employment is conditional upon my successful completion of a physical examination. I understand that there is no promise of any kind by BARC Developmental Services contained in any written or oral statements made by anyone interviewing me for this position.

I hereby give BARC Developmental Services the right to conduct a background investigation of myself as a condition of employment, which may include, but is not limited to, reference checks, criminal history and FBI clearances, child abuse history clearance, and motor vehicle record. I authorize persons, schools, current and previous employers and organizations named in this application (and any accompanying resume or application materials) to provide BARC Developmental Services any relevant information that may be required to arrive at an employment decision. I understand that BARC Developmental Services will consider such information personal and confidential. I release BARC Developmental Services, its officers, agents and associates, and all previous employers from any and all liability resulting from such verification and investigation.

Applicant Signature *

Date *

I have read and understand the above content and providing my name in this box acts as my electronic signature.

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Personal Information

Agency, Work, and Hours Information

Education

Employment History/Relevant Information

Driver Information

General Information

PLEASE READ AND COMPLETE THE FOLLOWING STATEMENTS CAREFULLY (*)

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