HRF-004/Rev. 01.01.2011

Position Applied for : ______________________________________________________ Date: _______________________

The Arc of San Diego Employment Application

Name Email Address Last First Middle Initial

Address Street City State Zip

Home Phone Work Phone Cell Phone

REFERRAL SOURCE: Please Check One

Newspaper Name: EDD/Cal Jobs Name:

Trade Publication Name: Employee Name:

Internet Name: Friend Name:

Walk-in Other (Please list)

SCHEDULE PREFERRED: (Check All That Apply)

Full-Time Part-Time On-Call/Temporary Work

If hired, on what day can you start? ____________________________

PERSONAL INFORMATION

Yes No Yes No

Have you ever been employed by The Arc of San Diego? If yes, please indicate when and where, name of former Supervisor and reason for leaving?

Do you have any relatives working for The Arc of San Diego? If yes, list names and relationship:

If hired, are you able to provide documentation required by the Immigration Reform and Control Act of 1986 to verify your right to work in the United States?

Are you at least 18 years old? (If under 18,your employment is subject to verification

that you are of minimum legal age.)

If hired, would you have reliable means of transportation to and from work?

Do you have a current valid Driver’s License? Driver License # State Exp Date Class

Is there any reason you would not be able to operate a motor vehicle to transport Arc employees, consumers or equipment if required?

Are you insurable?

YES NO

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? If No is checked, are there any accommodation(s) which would enable you to perform those job functions? Please describe the accommodations. (Note: we comply with the

ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Please advise us if any accommodation is needed to participate in the application process.) ______________________________________________________

HRF-004/Rev. 01.01.2011

Have you ever been convicted of a felony or misdemeanor (Exclude convictions for marijuana-related offenses more than two years old; convictions that have been sealed, expunged or legally eradicated) If yes please explain: _______________________________________________________________________________________________

YES NO

EDUCATION AND SKILLS

Circle or enter highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16+

School Location Major Diploma/GED Did you graduate?

(circle or check)

PROFESSIONAL CERTIFICATIONS/LICENSES

Name of Certification/License Location Expiration

Date Certification/License Number

LANGUAGE SKILLS

WORK HISTORY: List your paid or unpaid work experience in consecutive order with present or last employer listed first. Include military service, self-employment, volunteer experience, time in school, and periods of unemployment. If additional space is needed, attach additional sheets. APPLICANTS MUST FILL OUT THIS SECTION EVEN IF ATTACHING A RESUME. (If discharged from the military, please only list if you were adjudicatively discharged under “reason for leaving.”)

Name of Most Recent Employer From To Phone

Address Supervisor

Job Title

Duties/Responsibilities

Reason for Leaving

May we contact this employer for a reference?

Employer From To Phone

Address Supervisor

Job Title

Duties/Responsibilities

______________________________________ Speak Read Write

______________________________________ Speak Read Write

______________________________________ Speak Read Write

Yes / No

Yes / No

Yes / No

HRF-004/Rev. 01.01.2011

Reason for Leaving

May we contact this employer for a reference?

Employer From To Phone

Address Supervisor

Job Title

Duties/Responsibilities

Reason for Leaving

May we contact this employer for a reference?

Employer From To Phone

Address Supervisor

Job Title

Duties/Responsibilities

Reason for Leaving

May we contact this employer for a reference?

Employer From To Phone

Address Supervisor

Job Title

Duties/Responsibilities

Reason for Leaving

May we contact this employer for a reference?

REFERENCES: List below persons not related to you who have knowledge of your work performance and/or general character.

Name Title

Address City State Zip

Relationship Phone

Name Title

Address City State Zip

Relationship Phone

HRF-004/Rev. 01.01.2011

Name Title

Address City State Zip

Relationship Phone

PLEASE READ CAREFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW

______ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if it is discovered after I am employed, regardless of the time elapsed before discovery.

______ I hereby authorize The Arc of San Diego and /or its agents to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work and/or school records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

______ I acknowledge that employment with The Arc of San Diego, is entirely on an at-will basis and receipt of this application does not imply that I will be employed, nor is it a contract for employment. I understand that I can quit employment and that I can be terminated from employment at any time, for any reason or for no reason, with or without notice. I further understand and agree that the at-will nature of my employment, if offered, cannot be altered except by a writing signed by the Chief Executive Office or his/her designee.

Applicant Signature _______________________________________________________ Date ___________________________

Equal Opportunity Statement

All qualified employees and applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. The Arc of San Diego is an equal opportunity employer Minorities/Females/People with Disabilities/Protected Veterans/Sexual Orientation/Gender Identity.

If you'd like more information about your EEO rights as an applicant under the law, please download the available EEO is the Law. EEOis the Law English Version - Revised November 2009. EEO is the Law and EEO is the Law Supplement English Version - RevisedSeptember 2015. For Spanish employees and applicants, EEO is the Law Spanish Version - Revised November 2009. EEO is the Law and EEO is the Law Supplement Spanish Version - Revised September 2015.

The Arc of San Diego’s Core Values:

People First, Person-Centered One Team Community Partnership

Excellence Integrity & Accountability