APPLICANT INFORMATION

Last Name: First: M.I. Date:

Street Address: Apt. / Unit #:

City: State: Zip:

Phone: E-mail Address:

Date Available: Are you 18 years old or older? ______ Yes ______ No

Position Applied for:

Have you plead "guilty" or "no contest", or been charged with a crime?If yes, please give dates and details:

Answering yes to these questions does not constitute an automatic rejection to employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

EDUCATION

High School: Address:

From ToDid you graduate?

YES NO Degree:

College: Address:

From ToDid you graduate?

YES NO Degree:

Other: Address:

From ToDid you graduate?

YES NO Degree:

Other: Address:

From ToDid you graduate?

YES NO Degree:

CONNECT AND LEARN5100 BUCKEYSTOWN PIKE, SUITE 285

FREDERICK, MD 21704PHONE: 301-694-6422

FAX: 301-694-6426

Employment Application

Please Note: All experience must be documented in detail (including time frames and number of hours worked per week) on the application and your resume. Please document all experience acquired through paid work, volunteer work, and/or caring for a family member or friend with autism or other developmental disabilities.

PREVIOUS EMPLOYMENT: BEGIN WITH MOST RECENT EMPLOYMENT

Company: Phone:

Address: Supervisor:

Job Title: From: To:

Number of Hours worked per week:

Paid: ______ Volunteer Work: ______ Family Member/Friend: ______

Responsibilities:

Reason for Leaving:

Company: Phone:

Address: Supervisor:

Job Title: From: To:

Number of Hours worked per week:

Paid: ______ Volunteer Work: ______ Family Member/Friend: ______

Responsibilities:

Reason for Leaving:

Company: Phone:

Address: Supervisor:

Job Title: From: Job Title:

Number of Hours worked per week:

Paid: ______ Volunteer Work: ______ Family Member/Friend: ______

Responsibilities:

Reason for Leaving:

REFERENCESPlease list three professional references.

Name: Relationship:

Address: Phone:

Name: Relationship:

Address: Phone:

Name: Relationship:

Address: Phone:

ADDITIONAL QUALIFICATIONS: PLEASE TELL US ABOUT ANY OTHER EDUCATION, TRAINING, SKILLS, OR ACHEIVEMENTS THAT YOU FEEL SHOULD BE CONSIDERED.

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I further understand that I give Connect and Learn permission to contact my references.

Signature: Date: