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 or City
Zip Code
Social Security No.*
Telephone*
Email*
Position Desired*
Shift Desired

1st2nd3rd
Are you interested in:

Full-timePart-timePer-diem
Work History
Company Name/Address
Telephone
Supervisor’s Name
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Job Title
Reason for leaving
Company Name/Address
Telephone
Supervisor’s Name
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Job Title
Reason for leaving
Company Name/Address
Telephone
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?*

YESNO
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

	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?

YESNO
If no, please explain
Are you eligible to become Med Certified?

YESNO
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?

YESNO
If yes, State
License Number
Do you have any points/demerits within the last 3 years against your license?

YESNO
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?

YESNO
If yes, please explain
Are you currently employed full or part-time elsewhere?

YESNO
If yes, where?
What hours do you work?
Will you be keeping this position if employed by Alternatives, Inc.?

YESNO
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
Evening #
How long have you known this person?
Relationship?
Name
Address
Telephone # Day
Evening #
How long have you known this person?
Relationship?
Alternatives, Inc. P. O. Box 766 Cheshire, CT 06410
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*

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(Date)*

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Date
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Employment Application

TO BE CONSIDERED FOR EMPLOYMENT, YOU MUST:

Work History

General Information

Personal References