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Three Pearson Way Enfield, CT 06082 ... (Please check all that apply) Full-Time Part-time Sub Temp ... (For example, what ... pertaining to a finding of youthful delinquency or that a child was a member of a family in ... to the contrary are valid unless written under the signature of the President/ CEO. ... This form is voluntary.
Creating Opportunities for People. Three Pearson Way Enfield, CT 06082 (860) 741-3701 Fax: (860) 741-6870 http://www.alliedgroup.org [email protected]

An Equal Opportunity Employer We consider all applicants without regard to race, color, religion, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

PERSONAL INFORMATION

DATE: _________________________

Name: Current Address: Home Phone: (

City, State, Zip: )

Other Phone: (

E-Mail Address:

)

Are you legally able to work in the U.S.?

Yes

No

Previous Addresses for past seven years: (Starting with most recent)

Position applying for: Referral Source:

(Please check all that apply)

Newspaper (which?) ______

Employee

Salary Requirement: Prefer to work:

M

Walk-in

Full-Time

Part-time

State Employment Office

Sub Website

Temp Other

Date You Can Start: T

W

Th

F

Sa

Drivers License #: Has your license ever been revoked or suspended?

Su

Shift Preference: State:

Yes

Days

Evenings

Overnights

Expiration Date: No If “Yes” explain:

Have you ever been convicted of driving under the influence, leaving the scene or reckless driving? If “yes” explain:

Yes

No

List any accidents or violations in the past three years:

EDUCATION RECORD: (Name, City, State) High School

Graduation Date:

Business or Tech School

Graduation Date:

Undergraduate College

Degree:

Graduation Date:

Graduate School

Degree:

Graduation Date:

Other

Degree:

Graduation Date:

Any

PROFESSIONAL LICENSES OR CERTIFICATES (eg. CPR, First Aid, Med. Cert., CNA, HHA) Kind(s) of License or Certificate

Issued By

Expiration Date

VETERAN STATUS: Are you a Veteran?

Yes

No

If “Yes” which conflict?

WORK HISTORY (Please give information about your last three jobs, starting with the most recent.) 1-Employer

Supervisor:

Address: Employment Dates: FROM Title:

Salary /

/

TO

/

/

Specific Duties:

Name, if different, as it appeared on Employer’s record:

Reason for Leaving:

2-Employer

Supervisor:

Address: Employment Dates: FROM Title:

Salary /

/

TO

/

/

Specific Duties:

Name, if different, as it appeared on Employer’s record:

Reason for Leaving:

3-Employer

Supervisor:

Address: Employment Dates: FROM Title:

Salary /

/

TO

/

/

Specific Duties:

Name, if different, as it appeared on Employer’s record:

Reason for Leaving:

PROFESSIONAL REFERENCES: Note names, work address and day-time phone numbers of individuals who have supervised you. Provide work related references only. Title

1. Name Address Phone number during business hours: (

)

2. Name

Title

Address Phone number during business hours: (

)

3. Name

Title

Address Phone number during business hours: (

)

In your own words, include any other information you believe would help us make a decision to interview you. (For example, what value can you add to the agency?)

What would each employer say are/were your three major contributions?

What would each employer say are/were two areas that need development?

Allied Community Services conducts criminal background, drivers’ license and DDS Abuse and Neglect Registry checks as appropriate. This information will be available only to Human Resources and those individuals involved in interviewing the candidate. You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o, or 54-142, which are records pertaining to a finding of youthful delinquency or that a child was a member of a family in need of services, adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which you have been found not guilty or a conviction for which you have received an absolute pardon. If your only criminal record consists of items that have been erased under the statutes listed above, then you may state on this form you have not been arrested. Have you ever been convicted of a crime (excluding motor vehicle violations)?

Yes

No

If “Yes,” please explain:

Please Read and Sign I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of my driving record and all statements contained in this application including full release of information from my listed employers and references. It is my intention that this employer be fully informed of my background. I release from liability anyone listed on this application so that they can provide full information about my work and character, and release this employer from liability for seeking such information. I further understand that my driving and criminal record, as well the DDS Registry for substantiated abuse and neglect may be verified as part of the background check In the event of employment, should it be subsequently found that I omitted, falsified, or provided misleading information given in my application or interview(s), immediate discharge may result. I also understand that I am required to abide by all policies, rules, regulations, and procedures of the employer. I acknowledge that any employment relationship is on an “at will “ basis which means that I may resign at any time with or without notice and the employer may discharge me at any time with or without cause and with or without notice, and that no other statements to the contrary are valid unless written under the signature of the President/ CEO. If I need accommodation for employment I will so specify when interviewed. Signature:

Social Security Number:

-

-

Date:

FOR REVIEWER USE ONLY Interviewed:

Results:

If not hired, reason:

Yes

Hired

Not qualified

No show

Refused offer

No

Not Hired

More qualified applicant

Not interested

$ req too high

OTHER: _______________________________________________________ COMMENTS:

Rev. May 7, 2013

EOE FORM Allied Community Services, Inc. and its subsidiaries are Equal Opportunity and Affirmative Action Employers. To help us comply with government record keeping requirements, we would appreciate your completing the following information. This form is voluntary. If you choose not to provide the information, your decision will not affect your application. This data will be kept confidential, and will be kept separate from your application. _____________________________________ Name ____ Male

________/________/________ Date ___ Female

Race/Ethnicity Data (Please Check One) 

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.



White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.



Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.



Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.



Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.



American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.



Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Thank you for your assistance.

Rev 2/22/12

Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2017

Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:     

Blindness Deafness Cancer Diabetes Epilepsy

    

Autism Cerebral palsy HIV/AIDS Schizophrenia Muscular dystrophy

   

Bipolar disorder Major depression Multiple sclerosis (MS) Missing limbs or partially missing limbs

   

Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder Impairments requiring the use of a wheelchair Intellectual disability (previously called mental retardation)

Please check one of the boxes below: ☐

YES, I HAVE A DISABILITY (or previously had a disability)



NO, I DON’T HAVE A DISABILITY



I DON’T WISH TO ANSWER __________________________ Your Name

__________________ Today’s Date

Reasonable Accommodation Notice Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. 1

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.