Developmental Center & Workshop, Inc.
APPLICATION FOR EMPLOYMENT
Positions For Which You Are Applying
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DAY TREATMENT
JANITORIAL
Type of Employment You Will Accept
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Permanent Full-Time
Permanent Part-Time
Temporary Full-Time
Temporary Part-Time
Intermittent
Volunteer
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Social Security Number
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Are You A US Citizen?
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Please Select
Yes
No
If NO, can you legally work in the US?
*
Please Select
NA
Yes
No
Are you able to lift at least 50 pounds?
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Please Select
Yes
No
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Education
Are you a High School Graduate/GED?
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Please Select
Yes
No
If YES, please list name of school and year of graduation:
Do you have any other educational experience?
Please Select
Yes
No
If YES, please list the level of experience (ex. Undergraduate Degree, etc.)
Describe any professional licensing or professional affiliation you have:
List any additional educational or training information:
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Employment (Volunteer) History
Most Recent Employee (Volunteer Activity), any other relevant information or employment history please upload with resume.
Name of Employer:
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Date of Employment
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Month
-
Day
Year
Date
Address of Employer:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Employer:
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Please enter a valid phone number.
Name of Supervisor
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First Name
Last Name
Please describe duties and responsibilities performed for this job:
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Do you have a current driver's license?
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Please Select
Yes
No
If YES, list any driving violations in the last 10 years:
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Have you ever been convicted of a felony?
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Please Select
Yes
No
If YES, describe the circumstances and government agency to contact for confirmation.
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Character References
Please list three (3) individuals (not family members) in which to contact for a character reference:
Please list Name, Relationship, Home Phone and Work Phone of first reference:
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Please list Name, Relationship, Home Phone and Work Phone of second reference:
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Please list Name, Relationship, Home Phone and Work Phone of third reference:
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By signing this application, you are certifying that all statements are true and complete. We reserve the right to verify the information in this application. Supplying false information will result in your candidacy being terminated. DC&W has permission to contact employers, character references, and government agencies listed on this application.
Please sign here:
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Please upload your resume here:
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