Alternatives Application for Employment

Employment Application
Date

MonthDayYear
Date
Please read the following carefully before completing application.
TO BE CONSIDERED FOR EMPLOYMENT, YOU MUST:
1. Be at least 18 years of age.

2. Possess a valid Connecticut Driver’s license.

3. Have a high school diploma or GED.

4. Receive the annual flu shot.
Name
Other Last Names Used: (if any) i.e. Marriage
Address
Town
State
Zip Code
Social Security No.
Telephone
Format: (000) 000-0000.
Email
Position Desired
Shift Desired
Are you interested in:
Work History
Company Name/Address
Telephone
Format: (000) 000-0000.
Supervisor’s Name
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Job Title
Reason for leaving
Company Name/Address
Telephone
Format: (000) 000-0000.
Supervisor’s Name
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Job Title
Reason for leaving
Company Name/Address
Telephone
Format: (000) 000-0000.
Supervisor's Name
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Job Title
Reason for leaving
Have you been referred here?
By Whom
Please indicate the employers you do not wish to be contacted. In the absence of any such request, Alternatives Inc. has your permission to solicit information from previous employers.
DO NOT CONTACT
Reason

Education

Rows	Name/Location of School	Course of Study	No. of Years Completed	Did you Graduate:	Degree/Diploma Earned
High School
Business/Trade School
College

General Information
The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, sex or national origin. Federal law also prohibits discrimination on the basis of age with respect to certain individuals.
Are you able to perform all of the essential functions of this job with reasonable accommodation?
If no, please explain
Are you eligible to become Med Certified?
If no, please explain
How many times have you taken the Med-Cert exam?
Do you have a valid driver’s license to operate a motor vehicle?
If yes, State
License Number
Driver's License Upload

Cancelof
Do you have any points/demerits within the last 3 years against your license?
If yes, please explain
Do you have any motor vehicle violations, including suspensions, revocation, DUI, or any occurrence involving harm to any person or property in the last 3 years?
If yes, please explain
Are you currently employed full or part-time elsewhere?
If yes, where?
What hours do you work?
Will you be keeping this position if employed by Alternatives, Inc.?
Personal References
Please list at least two (2) personal references whom you have known for at least three years, not related to you, that we may contact.
Name
Address
Telephone # Day
Format: (000) 000-0000.
Evening #
Format: (000) 000-0000.
How long have you known this person?
Relationship?
Name
Address
Telephone # Day
Format: (000) 000-0000.
Evening #
Format: (000) 000-0000.
How long have you known this person?
Relationship?
Alternatives, Inc. P. O. Box 574 Naugatuck CT 06770
I,
Your name
, authorize Alternatives, Inc. to check my background in the following areas:
- State and National Sex Offenders Registry
- DDS/DCF Abuse & Neglect Registry
- Previous Employment Verification and Reference Checks
I also authorize and agree to participate in random drug testing throughout my employment with Alternatives, Inc.
Signature
(Date)

MonthDayYear
Date
Should be Empty:

Employment Application

TO BE CONSIDERED FOR EMPLOYMENT, YOU MUST:

Work History

General Information

Personal References