Job Application 1

Employment Application:
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.
Personal Information:
Full Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
YesNo
YesNo
If yes, please explain:
YesNo
YesNo
Employment Desired:
Position Applying For:
Date You Can Start

MonthDayYear
Salary Desired
YesNo
YesNo
Were you referred by a North Country Home Services Employee?
Employee Name
Education:
High School
Name of High School Attended
Yes
College
Name of College/University Attended
Yes
Area of Study/Degree
Graduate School
Name of Graduate School Attended
Yes
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Yes
Area of Study/Degree

List any Certifications:

Rows	License #	Type	State	Expiration Date
Certification 1
Certification 2
Certification 3

Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
YesNo
Supervisor Name
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Employment:
Previous Employer
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Supervisor Name
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Employer
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Supervisor Name
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
References:

Please list at least three (3) individuals who are qualified to describe your abilities. Previous employers, clergy, teachers, fellow workers, etc. (DO NOT use personal friends or relatives).
Reference 1
Name of Reference
Relationship
Years Acquainted
Phone
Email
Reference 2
Name of Reference
Relationship
Years Acquainted
Phone
Email
Reference 3
Name of Reference
Relationship
Years Acquainted
Phone
Email
Resume (Optional):
Resume and Cover Letter

Upload a File

Cancelof
Send Application:
I authorize the release of the following information under the provisions of the Privacy Act of 1974. Information is kept confidential.

I hereby authorize this company, and also authorize and request each former employer or person, firm or corporation given above as a reference, to answer all questions that may be asked regarding the information I have provided on this application for employment or concerning my work habits, character or skills.

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by contract unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

I understand, also, that I am required to abide by all rules and regulations of the employer.
Signature

Clear

Employment Application Self-Identification Form
The following information is being requested for Government reporting purposes and to measure our good faith outreach efforts. The information that you supply will not be used in our selection decision. Your submission of this information is optional. Failure to provide the information will not be used against you
Gender
Race
Veteran Status If you believe you belong to any of the categories of protected veterans listed below, please indicate by checking the appropriate box. As a Government Contractor, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake.
Definitions:
Qualified Disabled Veteran – a veteran of the US military, ground, naval or air service who is entitled to compensation under laws administered by the Secretary of Veteran Affairs, or a person who was discharged or released from active duty because of a service related disability.
Recently Separated Veteran – any Veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval or air service.
Active Duty Wartime or Campaign Badge Veterans - a veteran who served on active duty in the US military, ground, naval or air service during a war or in a campaign badge has been authorized, under the laws administered by the Department of Defense.
Armed Forces Service Medal – any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Veteran of the Vietnam Era – person who served on active duty for a period of more than 180 days, and was discharged or released there from with other than dishonorable discharge, if any part of such active duty occurred in the Republic of Vietnam between 2/28/61, and 5/7/75, or between 8/5/64 and 5/7/75 in
all other cases.

Definitions:
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.
Voluntary Self-Identification of Disability
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people
with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals
with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years. Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How do you know if you 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:
• Autism
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
• Blind or low vision
• Cancer
• Cardiovascular or heart disease
• Celiac disease
• Cerebral palsy
• Deaf or hard of hearing
• Depression or anxiety
• Diabetes
• Epilepsy
• Gastrointestinal disorders, for example, Crohn's Disease, or
irritable bowel syndrome
• Intellectual disability
• Missing limbs or partially missing limbs
• Nervous system condition for example, migraine headaches,
Parkinson’s disease, or Multiplesclerosis (MS)
• Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression
Chose from the following:
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.
Should be Empty:

Employment Application:

Personal Information:

Employment Desired:

Education:

Current Employment:

Previous Employment:

References:

Resume (Optional):

Send Application:

Employment Application Self-Identification Form

Voluntary Self-Identification of Disability