Crdage Cmmerce Center 10 Crdage Park Circle Suite 208 Plymuth, MA 02360 WWW.THEARCOFGP.ORG Email:Inf@Thearcfgp.rg PHONE: 508.732.9292 FAX: 508.732.9229 Applicatin fr Emplyment (Please print) Name Last First Middle Address Street City State Zip Phne #1 Phne #2 E-mail Address SSN Previus Name(s) wrked under Please check the specific Department yu are applying t: Family Supprt Adult Family Care DESE Emplyment Services Shared Living Psitin(s) applying fr (Be Specific): Date f applicatin: Date available t start: Type f emplyment desired: Full Time Part Time Temprary Educatinal (internship) Desired Salary/Wage: Referral Surce: Advertisement: (name & type) Internet: (website r ther) Friend/Relative: (name) Emplyee: (name) Emplyment Agency: (name) Walk-in Other: PERSONAL DATA
Are yu 18 years f age r lder? yes n Are yu legally eligible t wrk in this cuntry? yes n (Prf f U.S. citizenship r immigratin status will be required upn emplyment.) Have yu filed an applicatin with this r any ther Arc befre? Have yu ever been emplyed at this r any ther Arc? Frm T D yu have any relatives r friends wrking fr this r any ther Arc? D yu have a valid driver s license? yes n Has yur driver s license ever been suspended r revked? yes n If hired, wuld yu have reliable means f transprtatin t and frm wrk? yes n Type f transprtatin: car public transprtatin Is there any reasn yu wuld nt be able t transprt Arc emplyees, cnsumers r equipment if required? Is there anything that will interfere with yur ability t perfrm, n a regular basis, the essential duties f the jb fr which yu are nw applying? Are yu willing and able t wrk flexible shifts, which may include sme evenings? yes n Are yu willing and able t wrk ccasinal weekends? yes n If hired, d yu plan n having a secnd part-time r full-time jb at anther lcatin? yes n
EMPLOYMENT HISTORY Prvide the fllwing infrmatin beginning with the mst recent emplyer. See resume is nt acceptable. Emplyer Emplyed Frm (m/yy) T (m/yy) Starting Salary Ending Salary Address, City, State, Zip Starting Psitin Ending Psitin Reasn fr Leaving Supervisr Name, Title & Phne May we cntact? Duties Emplyer Emplyed Frm (m/yy) T (m/yy) Starting Salary Ending Salary Address, City, State, Zip Starting Psitin Ending Psitin Reasn fr Leaving Supervisr Name, Title & Phne May we cntact? Duties Emplyer Emplyed Frm (m/yy) T (m/yy) Starting Salary Ending Salary Address, City, State, Zip Starting Psitin Ending Psitin Reasn fr Leaving Supervisr Name, Title & Phne May we cntact? Duties Emplyer Emplyed Frm (m/yy) T (m/yy) Starting Salary Ending Salary Address, City, State, Zip Starting Psitin Ending Psitin Reasn fr Leaving Supervisr Name, Title & Phne May we cntact? Duties
Explain any perids f unemplyment fr mre than 30 days REFERENCES List the name, title/relatinship, number f years acquainted and phne number fr at least three prfessinal references. Name Title/Relatinship Years Acquainted Phne Number PLEASE PROVIDE THE FOLLOWING INFORMATION: Languages spken: English Spanish Other List any ther special skills r qualificatins acquired frm previus emplyment r ther experiences that make yu feel especially qualified fr this psitin. List special accmplishments, publicatin, and awards: Why are yu interested in wrking fr the Arc f Greater Plymuth?
The Arc f Greater Plymuth is cmmitted t wrking in partnership with persns with develpmental disabilities, and their families and cmmunities, in creating pprtunities t achieve their individual gals. Hw culd yu cntribute t this missin? List any additinal infrmatin yu wuld like t prvide r fr us t cnsider: It is understd and agreed that any misrepresentatin by me in this applicatin will be sufficient cause fr cancellatin f this applicatin and/r separatin frm the Emplyer s service if I have been emplyed. Furthermre, I understand that just as I am free t resign at any time, the Emplyer reserves the right t terminate my emplyment at any time, with r withut cause and withut prir ntice. I understand that n representative f the Emplyer has the authrity t make any assurances t the cntrary. The Emplyer is an equal pprtunity Emplyer. The Emplyer des nt discriminate in emplyment and n questin n this applicatin is used fr the purpse f limiting r excluding any applicant s cnsideratin fr emplyment n a basis prhibited by lcal, state r Federal law. This applicatin is current fr nly 60 days. At the cnclusin f this time, if I have nt heard frm the emplyer and still wish t be cnsidered fr emplyment, it will be necessary fr me t fill ut a new applicatin. I give the emplyer the right t investigate all references and t secure additinal infrmatin abut me, if jb related. I hereby release frm liability the emplyer and its representatives fr seeking such infrmatin and all ther persns, crpratins, r rganizatins fr furnishing such infrmatin. Signature f Applicant Date
Crdage Cmmerce Center 10 Crdage Park Circle Suite 208 Plymuth, MA 02360 WWW.THEARCOFGP.ORG Email: Inf@Thearcfgp.rg PHONE: 508.732.9292 FAX: 508.732.9229 CORI REQUEST FORM The Arc f Greater Plymuth has been certified by the Criminal Histry Systems Bard fr access t cnvictin and pending criminal case data. As a (prspective) emplyee/cntractr/vlunteer fr the psitin f, I understand that a criminal recrd check will be cnducted fr cnvictin and pending criminal case infrmatin nly and that it will nt necessarily disqualify me. The infrmatin belw is crrect t the best f my knwledge. (Prspective) Emplyee/Cntractr/Vlunteer Signature (PROSPECTIVE) EMPLOYEE/CONTRACTOR/VOLUNTEER INFORMATION (PLEASE PRINT) LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME OR ALIAS (IF APPLICABLE) PLACE OF BIRTH : - - DATE OF BIRTH: SOCIAL SECURITY NUMBER ID Theft Index PIN* (REQUIRED) (If applicable) MOTHER S MAIDEN NAME CURRENT & FORMER ADDRESSES SEX: HEIGHT: FT IN WEIGHT: EYE COLOR: STATE DRIVER S LICENSE NUMBER: (Include state f issue) *THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING GOVERNMENT ISSUED PHOTOGRAPHIC IDENTIFICATION: REQUESTED BY: (Signature f CORI Authrized Emplyee) *The CHSB Identify Theft Index PIN number is t be cmpleted by thse applicants that have been issued an Identity Theft Index PIN Number by CHSB. Certificated agencies are required t prvide all applicants the pprtunity t include this infrmatin t ensure the accuracy f the CORI request prcess. ALL CORI REQUEST FORMS THAT INCLUDE THIS FIELD ARE REQUIRED TO BE SUBMITTED TO THE CHSB VIA MAIL OR BY FAX TO 617-660-4614.
Crdage Cmmerce Center 10 Crdage Park Circle Suite 208 Plymuth, MA 02360 WWW.THEARCOFGP.ORG Email:Inf@Thearcfgp.rg PHONE: 508.732.9292 FAX: 508.732.9229 REGISTRY OF MOTOR VEHICLES PERSONAL INFORMATION REQUEST FORM The fllwing infrmatin is needed in rder fr The Arc f Greater Plymuth t Request access t mtr vehicle driver recrd(s), including persnal infrmatin as Defined in 18 U.S.C. 2725. Emplyee Name: Hme Address: City/State/Zip: Date f Birth: Driver s License #: Scial Security #: Vehicle Registratin #: Vehicle Title #: Vehicle Identificatin (VIN) #:
D Nt sign the fllwing frm until ntarized. There is a ntary at The Arc ffice n Wednesdays. Or, yu may bring t yur bank t have ntarized n yur wn, and then submit t The Arc. Thank yu
Crdage Cmmerce Center 10 Crdage Park Circle Suite 208 Plymuth, MA 02360 WWW.THEARCOFGP.ORG Email:Inf@Thearcfgp.rg PHONE: 508.732.9292 FAX: 508.732.9229 Department f Children and Families Backgrund Recrd Check I,, (First name) (Middle name) (Last name) Authrize the Department f Children and Families t perfrm a search f its recrds fr any substantiated reprts f child abuse f neglect r designatin as an Alleged Perpetratr. I authrize The Arc f Greater Plymuth, Inc. t receive the results f this search. Signature f Prspective Emplyee Date Date f Birth Scial Security Number Current Address Prir Address COMMONWEALTH OF MASSACHUSETTS Cunty Date: On this day f, 2013, befre me, the undersigned ntary public, persnally appeared, prved t me thrugh satisfactry evidence f identificatin which were, t be the persn whse name is signed n the preceding r attached dcument wh have affirmed t me that the cntents f the dcuments are truthful and accurate t the best f his/her knwledge and belief. REVISED: 5/21/2013 Ntary