Employment Application for Safety

101 Independence Lane NW * (706) 842-2110

info@ambergrace.com * www.ambergrace.com
Employment Application
Reply To
example@example.com
Amber Grace Community

First NameLast Name
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Please attach cover letters, resumes, and any other pertinent documents you feel necessary using this link. PDF or Word files are preferred. Thank you!

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Today's Date

MonthDayYear
Date
Contact Information
Name

First NameMiddle InitialLast Name
Preferred Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.
Contact Email
example@example.com
Job Type
Position for which you are applying?
Date available to start work:

MonthDayYear
Date
Are you related to any current Amber Grace employees?
Name
Relationship
Name
Relationship
Additional Information
Are you legally authorized to work in the United States?

Will you now or in the future require sponsorship for employment visa status? (e.g. H-1B visa status)
Have you ever been convicted of a felony?
If yes, please identify (1) the offense(s) and the date(s) of conviction, (2) the state where the conviction occurred, (3) the sentence, and (4) a summary of the circumstances. Convictions will not necessarily disqualify an applicant from employment, but will be considered in relation to the specific circumstances and specific job requirements. Failure to answer the question fully and accurately could result in denial or termination of employment. Please note: You do not have to answer "yes" to any conviction that has been erased, expunged, vacates, annulled, pardoned, set aside, sealed, or otherwise eradicated by a court.
Have you ever been involuntarily terminated or dismissed from a prior job?
If yes, please provide a summary of the circumstances. Failure to answer the question fully and accurately could result in denial or termination of employment.

Education

Education

Rows	Name & Location of School	Number of Years Completed	Did you graduate?	Degree and Major
High School
College/ University
College/ University
Graduate School
Other
Other

Employment History
Please list your past three employers or the most recent five years of employment history-- whichever is greatest. If you do not have five years of employment history, list the history you have.
Name of Employer:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Job Title:
Reason for Leaving:
Responsibilities:
Supervisor:
Phone Number:
Format: (000) 000-0000.
Name of Employer:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Job Title:
Reason for Leaving:
Responsibilities:
Supervisor:
Phone Number:
Format: (000) 000-0000.
Name of Employer:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Job Title:
Reason for Leaving:
Responsibilities:
Supervisor:
Phone Number:
Format: (000) 000-0000.
4/6

Professional References (Please list three.)
Name:
Relationship:
Cell Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Email:
example@example.com
Name:
Relationship:
Cell Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Email:
example@example.com
Name:
Relationship:
Cell Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Email:
example@example.com
Personal References (Please list two-these may be personal or professional.)
Name:
Relationship:
Cell Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Email:
example@example.com
Name:
Relationship:
Cell Phone:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
Email:
example@example.com
What interests you about working for Amber Grace specifically in this position?

Why do you want to work with adults with intellectual and developmental disabilities (IDD)?
Have you worked with adults with IDD before?
Have you been involved with people with IDD outside of employment?
What is your philosophy on behavior management of adults with intellectual and developmental disabilities?
6/6

Please read the following statements carefully and sign:
Amber Grace Community appreciates your willingness to share your skills. Providing safe and secure programs for Adults with IDD is of utmost importance to us. The information gathered in this application is designed to help us provide the highest quality programs for the people of our community.
Amber Grace Community has zero tolerance for abuse and will not tolerate the mistreatment or abuse of Adults with IDD in its programs. Any mistreatment or abuse by an employee or volunteer will result in disciplinary action, up to and including termination of employment or volunteer service and cooperation with law enforcement.
Amber Grace Community takes every allegation of abuse or misconduct seriously and will fully cooperate with the authorities to investigate all cases of alleged abuse or misconduct. Employees and volunteers shall cooperate with any external investigation by outside authorities or internal investigation conducted by the organization or persons given investigative authority by the organization. An employee or volunteer's failure to cooperate with an investigation will result in disciplinary action up to and including termination of employment or dismissal from the organization.
Signature of Applicant*
Signature of Applicant
Date

MonthDayYear
Date
I certify that all of the answers given in this application are true and complete to the best of my knowledge and are subject to verification by the Amber Grace, Inc. If I am employed, I understand that false or misleading information given in my application or interview(s) may result in termination.
I understand that completion of this application does not indicate that there are any positions currently open and does not obligate Amber Grace to hire me. I further understand that, if employed, my employment with Amber Grace would be at-will, meaning that my employment would not be for any specified period of time, that I could resign my employment with Amber Grace at any time for any reason, and that Amber Grace could terminate my employment at any time for any reason, with or without cause or advance notice, as permitted under applicable federal, state and local law. I understand and agree that any employee handbook which I may receive will not constitute an employment contract and will not confer upon me any contractual rights, but will be merely a statement of Amber Grace's current policies which may be changed at its sole discretion.
I understand that once a conditional offer of employment has been made, I will be requested to submit to a physical examination by a licensed healthcare provider, including a tuberculosis screening, and that, as a condition of employment, I must consent to undergo such examination and authorize the release of pertinent information to Amber Grace.
I certify that I have read the foregoing and understand that all such statements apply to my application and to my subsequent employment, if any.
I verify that my typed name below, when submitted electronically, constitutes my signature for the purposes of this application.
Signature of Applicant
7/6

Employment Application

Contact Information

Job Type

Additional Information

Education

Employment History

Professional References (Please list three.)

Personal References (Please list two-these may be personal or professional.)