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Full Name (Last, First, Middle)

Street Address 1

E-mail

Street Address 2

State

City

Zip Code

Phone Number

Position Applying For

Date Available to Start

Looking for:

Full Time

Part Time

Provisional

Weekdays ONLY

Weekends ONLY

Weekdays AND/OR Weekends

Day Hours (ex. 9am-5pm)

Afternoon/Evening Hours (ex. 3pm-11pm)

Night Hours (ex. 11pm-9am)

Have you ever worked for BARC Developmental Services?

Yes

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

How did you learn of our organization?

Indeed

Newspaper

Website

Referred

Walk-in

Other

EDUCATION

Name of High School

Location

Did you Graduate?

Yes No

Name of College/University/Other

Major/Minor

Location

Number of Years

Did you Graduate?

Yes No

Type of Degree or Diploma:

Name of Graduate School

Major/Minor

Number of Years

Location

Did your Graduate?

Yes

Type of Degree or 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/Zip

Phone

Name of Supervisor

Dates Employed

Ending Weekly Pay

Number of Hours Worked per Week

State your Job Title and Describe Work Performed

Reason for Leaving

May We Contact this Employer?

Yes No

If no, explain

Company Name 2

Mailing or Street Address

City/State/Zip

Phone

Name of Supervisor

Dates Employed

Ending Weekly Pay

Number of Hours Worked per Week

State your Job Title and Describe Work Performed

Reason for Leaving

May We Contact this Employer?

Yes No

If no, explain

Company Name 3

Mailing or Street Address

City/State/Zip

Phone

Name of Supervisor

Dates Employed

Ending Weekly Pay

Number of Hours Worked per Week

State your Job Title and Describe Work Performed

Reason for Leaving

May We Contact this Employer?

Yes No

If no, explain

DRIVER INFORMATION

License Number

State

Expiration Date

Experience (Number of Years)

Types of Vehicles

Number of Citation in Past Three Years

Number of Moving Violations in Past Three Years

Number of Accidents in Past Three Years

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

Yes No

Do you have a valid driver's license?

Yes No

Have your driving privileges ever been suspended or license revoked?

Yes No

If yes give dates:

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 No

If 'Yes', what kind of training or education did you receive in the military?

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

Yes

If 'Yes', please explain giving date, charge, disposition, and any other details you feel appropriate. NOTE: A conviction does not constitute an automatic bar to employment. Factors such as seriousness of the infraction, date of conviction and how the conviction relates to fitness to perform the job in question will be considered.

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

Yes No

Are you at least 18 years old?

Yes No

State other names under which you have worked or attended school:

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

Contact Name and Phone Info

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

Contact Name and Phone Info

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 name 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.

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

APPLICANT SIGNATURE

DATE