Application for Employment – Full Circle Restoration

Equal access to programs, services and employment opportunities is granted to all persons without regard to sex (including pregnancy) race, color, religion, national origin, citizenship, age, disability, genetic information, or any other basis protected by federal, state, and/or local law.

In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of accommodation include making a change to the application process; providing written materials in an alternate format such as braille, large print or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions.

Name*
First Middle Last
Applicant ID#
Address*
Street Address City State ZIP Code
Primary phone*
Secondary phone
Email*
Position(s) applied for*
Referral Sources
e.g., Walk-in, Job Posting, Company Website, etc.
Employment Eligibility
If necessary, what is the best time to call you?

: HH

MM

AM/PM
Preferred Phone Number
- Primary Phone
- Secondary Phone
May we contact you at work?
- Yes
- No
Work phone number*
Best time to call*

: Hours

Minutes

AM/PM
If you are under 18 and it is required, can you furnish a work permit?*
- N/A
- Yes
- No
Please explain*
Have you submitted an application here before?
- Yes
- No
What position(s)*
Date*
MM slash DD slash YYYY
Have you ever been employed here before?
- Yes
- No
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Are you requesting reemployment following an extended military leave of absence from this company?*
- Yes
- No
If “Yes”, additional information may be requested
Are you lawfully authorized to work in the United States*
- Yes
- No
Date available to start work*
MM slash DD slash YYYY
Desired salary range or hourly rate*
Per*
Type of Employment Desired*
- Full-Time
- Part-Time
- Educational Co-Op
- Seasonal
- Temporary
Will you relocate if the job requires it?*
- Yes
- No
Will you travel if the job requires it?*
- Yes
- No
If they have been explained to you, are you able to meet the attendance requirements of the position?*
- N/A
- Yes
- No
Will you work overtime if required?*
- Yes
- No
If "no", please explain*
Are you able to preform the "essential functions" of the job for which you are applying (with or without reasonable accomodation)*
- Yes
- No
- Need more information about the jobs “essential functions”
This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.
Drivers License Number
Required if driving may be required in the position for which you are applying:
State:
Have you ever been bonded?*
- Yes
- No
Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?*
- Yes
- No
If "Yes", please explain*
Employment History
Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.
Employer
Telephone #
Street Address
City
State
Starting Job Title / Final Job Title
Dates Employed
MM slash DD slash YYYY

to:
MM slash DD slash YYYY

Immediate supervisor and title (for most recent position held)
Why did you leave?
Summarize the type of work and job responsibilites
What did you like most about the position?
What did you like least about the position?
Employment History
(continued)
Explain any gaps in your employment, other than those due to personal illness, injury, or disability.
If not addressed on previous page, have you ever been fired or asked to resign from a job?*
- Yes
- No
If "yes", please explain*
Skills and Qualifications
Summarize any special training, skills, languages, licenses, and/or other certificates that may assist you in performing the position for which you are applying
Computer Skills
(Include software titles and level of experience, such as basic, intermediate, or advanced.)

Word Processing

Spreadsheet

Presentation

Internet

Other

Other

Other

Educational Background
Starting with your most recent school attended, please provide the following information:
Starting with your most recent school attended, please provide the following information:
School (Include City and State) Years attended Completed (eg: Degree, GED, Diploma) GPA / Rank Major / Minor
References
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name Title Relationship to you Telephone Email # of years known
Related Information
When answering these questions, please exclude any information that would reveal sex (including pregnancy), race, color, religion, national origin, citizenship, age, disability, genetic information, or other similarly protected status.
To what job-related organizations (professional, trade, etc) do you belong?
List special accomplishments, publications, awards, etc.
List any relevant volunteer work.
Is there any other job-related information you want us to know about you?
Applicant Statement
Consent*
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct.
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, resumé, 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 truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

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

I understand that this application remains current for 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. 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 written and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete and I-9 Form in this regard.

I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer’s affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer.

This company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an application from consideration for employment on the basis of his or her race, religion, color, sex (including pregnancy, sexual orientation, and gender identity), age, national origin, disability, marital status, height, weight, genetic information, or any other protected status under applicable federal, state, or local law.

Mandatory Employer Disclosures

Notice to Maryland applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

Notice to Massachusetts applicants: It is unlaWful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
Notice to Rhode Island applicants: This company complies with Rhode Island law prohibiting smoking in enclosed areas within places of employment.
Notice to North Dakota applicants: This company complies with North Dakota law prohibiting smoking within 20 feet of entrance and inside places of employment.
Notice to Indiana applicants: This company complies with Indiana law prohibiting smoking in enclosed areas within places of employment.
Notice to Illinois applicants: Please be advised pursuant to Illinois law, applicants are not obligated to disclose expunged juvenile records of adjudication, arrest, or conviction.

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) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.
Digital Signature*
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
First
Phone
This field is for validation purposes and should be left unchanged.

School (Include City and State)	Years attended	Completed (eg: Degree, GED, Diploma)	GPA / Rank	Major / Minor

Name	Title	Relationship to you	Telephone	Email	# of years known

Employment Eligibility

Employment History

Employment History

Skills and Qualifications

Educational Background

References

Related Information

Applicant Statement