The Arc of Salem County

The Arc is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, religion, sex, sexual orientation, national origin, age, marital or veteran status, the presence of a non-job related medical condition or disability, or any other legally protected status.

Position applied for

Choose One

Referral Source

List any relatives currently employed by The Arc and your relationship.

Have you filed an application before?

If yes, give date

Are you employed now?

If yes, may we contact your employer?

Name

First NameMiddle NameLast NameSuffix

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Best number to reach you?

Area CodePhone Number

E-mail

Are you at least 18 years of age?

Do you possess a valid NJ driver's license, not probational or provisional?

Exp. Date

Do you have 5 or less points on your driving record?

EDUCATIONAL BACKGROUND:
A. List last three (3) schools attended, including high school: B. List number of years completed; C. Indicate degree, diploma earned, if any; Proof of degree/diploma/GED required.

Rows	A. Name of School	B. Years Completed	C. Degree Sought	D. Graduated Y/N
High School
College
College

REFERENCES: List name and telephone number of three business/ work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you.

Rows	Name	Telephone	Years Known
Reference One
Reference Two
Reference Three

Employment History
List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below.

Employer 1

NameTelephone

Address

Street Address

Street Address Line 2

CityState / Province

Job Title

Immediate Supervisor and Title

May we contact for references?

Rows	Start Date	End Date
Job Summary

Summarize the nature of your work performed and responsibilities

Reason for leaving

Employer 2

NameTelephone

Address

Street Address

Street Address Line 2

CityState / Province

Job Title

Immediate Supervisor and Title

May we contact for references?

Rows	Start Date	End Date
Job Summary

Summarize the nature of your work performed and responsibilities

Reason for leaving

If you do not have any further positions to list, please enter N/A in each field.

Employer 3

NameTelephone

Address

Street Address

Street Address Line 2

CityState / Province

Job Title

Immediate Supervisor and Title

May we contact for references?

Rows	Start Date	End Date
Job Summary

Summarize the nature of your work performed and responsibilities

Reason for leaving

Employer 4

NameTelephone

Address

Street Address

Street Address Line 2

CityState / Province

Job Title

Immediate Supervisor and Title

May we contact for references?

Rows	Start Date	End Date
Job Summary

Summarize the nature of your work performed and responsibilities

Reason for leaving

Comments including explanation of gaps in employment

Last 4 digits of your Social Security

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration status is required upon employment)

As this agency serves people with developmental and intellectual disabilities, The State of NJ Department of Health requires employees to submit to fingerprinting.

Have you ever been civilly or criminally liable of a crime against a person with a developmental or intellectual disability in the state of NJ?

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?

Answering "yes" to this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness, and nature of the violation, rehabilitation, and position applied for will be taken into account.

I AGREE

AGREEMENTS

This serves as notice that The Arc of Salem County requires results of a satisfactory drug and alcohol screening test prior to beginning employment. Thereafter, tests will be performed on a random basis and will be conducted at a local medical site. Under the State of NJ Department of Health regulations, positive results for any controlled substance, illegal drug, or marijuana, even if medically prescribed, may preclude you from employment consideration and/or may result in immediate termination of employment. Signing below indicates the acknowledgement of this policy.

I AGREE

I give the Agency the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Agency and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. It is understood and agreed that any misrepresentation by any in the application will be sufficient cause for cancellation of this application and/or termination from the company’s service if I have been employed.

I AGREE

By signing below, I understand and agree that The Arc of Salem County makes no representation that employment with the Agency is a guarantee of continued employment. I further understand that my employment will be on an at-will basis, and that neither I, nor the company, or its representatives have entered into a contract regarding the duration of my employment. Both The Arc and I are free to terminate my employment with The Arc of Salem County at any time, with or without cause or advanced notice. I further understand that no representative of the Agency has the authority to make or imply any assurances to the contrary.

Full Name

First NameMiddle NameLast Name

Signature

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