Date:
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Last Name
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First Name:
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Middle Initial:
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Other names used:
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PRESENT ADDRESS
Street Address:
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City:
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State:
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Zip Code:
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Home Phone:
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Business Phone:
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May we call you at work?
Yes
No
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PERMANENT ADDRESS
Street Address:
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City:
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State:
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Zip Code:
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Position Desired:
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Full-time
Part Time
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Overtime?
Yes
No |
When will you be available
to begin work:
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If not availble for full-time work, what hours can you work:
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Have you ever applied for employment with us??
Yes
No
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EDUCATION
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High School
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College
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| Diploma?
Yes
No |
Highest Degree:
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| Do you have a valid driver's license? (For positions that require driving): |
Yes
No |
| Have you had a valid driver's license for at least 12 months? |
Yes
No |
Do you have any special skills training or skills? (languages, machine operation, CPR, first aid, etc.)
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| If hired, can you provide wrtten evidence that you are authorized to work in the US? |
Yes
No |
| Have you ever been convicted of a felony or misdemeanor, in any jurisdiction, which has not been annulled, expunged or sealed by the court? (Conviction record may not necessarily be a bar to employment) |
Yes
No |
If yes, describe in full:
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| Are there any pending criminal charges against you? |
Yes
No |
If yes, describe in full:
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| Are you now, or has a government agency proposed that you be, excluded from participating in a government program such as Medicare or Medicaid? |
Yes
No |
If yes, please describe the circumstances and indicate the period of exclusion:
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Have you ever been a member
of the armed forces? |
Yes
No |
If yes, what branch?
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1) Any material misstatement or deliberate omission of a relevant fact by me in this application, a resume, and/or attachments will be sufficient cause for terminating the consideration of my application or my subsequent employment. |
5) If I am employed by ARC, my employment and compensation may be terminated at any time at the option of either ARC or myself, with or without cause, and with or without notice. |
2) ARC may procure or have prepared an investigative report to verify any information affecting my employment including but not limited to a criminal background check, fingerprinting to meet OMRDD regulations for people who have regular and substantial unsupervised physical contact with consumers, a credit check and/or a driver's license check. |
6) If I am employed by ARC, I will abide by ARC’s policies and procedures. |
3) My employment with ARC may be subject to satisfactory completion of a physical examination, which will include a drug and alcohol screening test, conducted at the direction of ARC prior to my employment or at such time as may be required by ARC. |
7) If my application for employment or my employment is subject to a local ordinance, state statute or law that supersedes any provision of the application form, that that ordinance, statute or law will apply. |
4) Policy manuals, employee handbooks, and statements of employee benefits are informational only and do not create an employment contract or alter my status as an at-will employee, and no employee or representative of ARC, other than an officer of ARC, has authority to enter into any agreement which alters my status as an at-will employee. |
8) I authorize the institutions and individuals listed on this application to give ARC any and all information they may have, personal or otherwise, concerning my previous character, and I release all parties from any liability that may result from furnishing such information to ARC. |
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| Signature of applicant:
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PROFESSIONAL REFERENCES
Please include all of your eomployment or other activity in chronological order, including military and/or volunteer service for the past ten (10) years starting with your most recent employer.
1. Name of Employer:
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PERSONAL REFERENCES
1. Name
1. Name
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