Careers Form

Applicant's Information

First Name *

Last Name *

Middle Initial *

Number *

Street *

City *

State *

Zip Code

Phone Number *

Social Security Number

Email *

Are you 18 years of age or older?

Yes

Are you a military Veteran?

Yes

Are you legally able to work in the United States?

Yes

Dates of?

Active Duty from

to:

Driver's License State:

License Number

Have you worked for Promise before?

Yes

When?

and Position

Employment Desired

Job Title

Date you can start

Wage Desired

Are you available for work:

Full Time

Part-Time

Shift Work

Seasonal

Do you prefer to work with clients who are:

Children

Adults

Seniors

No Preference

Education

Name of School

Address

Major

Degree

Completed

Yes

Highschool/GED

Technical/Vocational

College/University

Other

Area of Concentration and/or degree(s), Certificates, Licenses, Endorsements:

Other Training or Skills (Office Machines Operated, Special Courses, Computer Skills, Used of Word, Excel etc.

Work History

If you are currently employed, may we contact your employer?

Yes

Begin with Current or Most Recent Employer or Position with Employer

(1) Employer

Address

Supervisor

Phone Number

Starting Date

Ending Date

Ending Wage

Position

Description of Job

Reason for Leaving:

(2) Employer

Address

Supervisor

Phone Number

Starting Date

Ending Date

Ending Wage

Position

Description of Job

Reason for Leaving:

(3) Employer

Address

Supervisor

Phone Number

Starting Date

Ending Date

Ending Wage

Position

Description of Job

Reason for Leaving:

REFERENCES

Promise requests that all applicants submit (3) references, which may include: current of former employers, supervisors, teachers or others qualified to objectively evaluate your ability to work in the position for which you have applied. Please list the reference information identified below. Promise will be contacting each reference listed.

(1) Name

Relationship to Applicant

Address

Fax Number

Daytime phone number:

Nighttime phone number

(2) Name

Relationship to Applicant

Address

Fax Number

Daytime phone number:

Nighttime phone number

(3) Name

Relationship to Applicant

Address

Fax Number

Daytime phone number:

Nighttime phone number

Application declartion of understanding

I understand that Promise Day Habilitation may conduct and investigate of the information I have noted on this application by contacting my prior employer and references.

I understand that any falsification, misrepresentation or omission of information discovered as a result of this investigation may terminate the employment process or if hired, may subject me to the immediate termination of my employment with Promise Day Habilitation.

I understand that by signing below, Promise Day Habilitation will check the child and /or adult abuse registries as well as the DCI for a criminal records check. The post-employment discovery of conviction information not provided here will subject me to the disciplinary policy. This will likely result in termination of my employment.

I understand that before I may be allowed to drive on agency business vehicle, a driving records check will be conducted. * I understand that nothing contained in this application should be considered as a contract of employment.

I acknowledge that I am an employee at will.

Name of Applicant *

Date

Employee Background Check Required Information:

The following named individual has made an application with Promise Day Habilitation for

Last Name

First Name

Middle Name

Date of Birth

Social Security Number

Maiden, Alias or Former Name

Current Address

Telephone Number

Driver\’s License Number

State

Expiration Date

Gender

Male

Female

I authorize the FBI and New Jersey Division of Criminal Investigation to disclose all criminal history record information to All Promise Day Habilitation for the purpose of employment as specified above. The expiration of this authorization shall be for a period of one year from the date of my signature.

Name of Applicant

Date: