Supporting People With Developmental Disabilities Since 1950 | St. Louis Arc

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Date of Application: 5/15/2006
Position Applying For: General Position
Location of Position Applying For: St. Louis Arc

Identifying Information:
= Required Fields
First Name: Middle Initial:
Last Name:
Present Mailing Address:
City:
State:
Zip Code:
Home Phone: ###-###-####
Work or Message Phone: ###-###-####
E-mail address: (if any)
Are you at least
18 years of age?
Are you employed now?
Do you wish to work:
If Part-time, specify days and hours:
Sun Mon Tue Wed Thu Fri Sat
Availability:
(Please check all that apply)
Holidays
Rotating Shifts
Your minimum hourly
wage requirement:
Date available for work:
Other skills:
Professional Licenses:

Educational Background:
Name, City, State Degree/Certificate Graduated?
High School:
College:
Trade or Business:
Other:

Professional License and/or Certificates:

Type Organization or State Issued Date Issued Number

Employment History:
In the following spaces please give a complete record of your employment. Begin with your most recent employment and work back. If you wish to include more than three past employers, please use the space below titled "Additional Employers".
Employer:
Address:
Telephone: ###-###-####
Supervisor:
Starting Position: Last Position:
Starting Salary: Final Salary:
Employed From: (MM/YY) Employed To: (MM/YY)
Duties:
Reason for Leaving:
Employer:
Address:
Telephone: ###-###-####
Supervisor:
Starting Position: Last Position:
Starting Salary: Final Salary:
Employed From: (MM/YY) Employed To: (MM/YY)
Duties:
Reason for Leaving:
Employer:
Address:
Telephone: ###-###-####
Supervisor:
Starting Position: Last Position:
Starting Salary: Final Salary:
Employed From: (MM/YY) Employed To: (MM/YY)
Duties:
Reason for Leaving:

Additional Employers

Questionnaire
Have you previously applied for employment with us?
If yes, when and where?
Have you previously been employed with St. Louis Arc?
If yes, when and where?
Are any of your relatives employed with St. Louis Arc?
If yes, where?
Do you expect to work elsewhere (Full or Part time) if employed with us?
If yes, please explain:
In order to permit a check of your work and education records, please indicate any other names you have used in the past:
Have you ever pled 'guilty' or 'no contest' to, or been convicted of a crime?

If yes, please explain:


(Note: Answering 'yes' to the previous question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, and position applied for will be taken into account.)
For driving positions only: Do you have a valid driver's license?
License number and State issued:


Use this space to give us further information which you think is important for us to know in relationship to this job.

Agreement
Please read the following statements carefully and indicate you have done so by entering your name and today's date in the fields below:

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to
(i) cancel further consideration of this application,
or
(ii) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. I understand that I am an at-will employee. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I have read, fully understand, and accept all terms of the above Applicant Statement.
Name: (First MI. Last)
Date Today: