Employment Application-CONNECTIONS

Performance of Duties
PLEASE READ: If you are to be hired as an employee with Connections, you may be asked to assist clients in daily personal care such as hygiene (bathing, hair care, etc.), toileting (including catheters), dental care and more. Client care may consist of occasional lifting or assistance with carrying. At times, you may be required to redirect clients who are showing verbally or physically aggressive behaviors.
Please list any concerns you have regarding your ability to perform any/all aspects of the position your are applying for:
ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING WITH OR WITHOUT REASONABLE ACCOMODATIONS?*

YesNo
Education
Did you graduate from High School or obtain your GED?*

YesNo
Please let us know the name of the High School and the location of the High School you attended. If you received your GED, just type in GED.
Did you attend College?*

YesNo
Please let us know the name of the College and location of the college you attended.
Did you receive a degree or diploma?

YesNo
What type of degree or diploma did you receive and what was it in?
Please let us know about any OTHER training or education you have acquired.

Current/Previous Employment
Starting with your most recent employer, provide the following information:
Employer Name or Business (Most Recent)*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number

Area CodePhone Number
Business Website
Example: www.businesswebsite.com
Job Title*
Name of Immediate Supervisor*

First NameLast Name
May we contact this supervisor?*

YesNo
Please let us know the beginning date of employment.*

MonthDayYear
Date
Please let us know the ending date of employment.*
Summary of Job Responsibilities*
Reason for leaving?
Employer Name or Business
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number

Area CodePhone Number
Business Website
Example: www.businesswebsite.com
Starting Job Title
Ending Job Title
Name of Immediate Supervisor

First NameLast Name
May we contact this supervisor?

YesNo
Please let us know the beginning date of employment.

MonthDayYear
Date
Please let us know the ending date of employment.
Summary of Job Responsibilities
Reason for leaving?
Employer Name or Business
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number

Area CodePhone Number
Business Website
Example: www.businesswebsite.com
Job Title
Name of Immediate Supervisor

First NameLast Name
May we contact this supervisor?

YesNo
Please let us know the beginning date of employment.

MonthDayYear
Date
Please let us know the ending date of employment.
Summary of Job Responsibilities
Reason for leaving?
Please explain any gaps in your employment other than those due to personal illness, injury or disability:
If not addressed above, have you ever been fired or asked to resign from a job?

YesNo
If yes, please explain.

Notification to Applicant
CONNECTIONS is an equal opportunity employer and will not discriminate against any applicant or employee on any grounds protected under federal, state or local law including race, color, creed, religion, age, sex, national origin, ancestry, marital status, handicap, disability related to pregnancy or childbirth, sexual preference, membership or activity in any local commission, status regarding public assistance, membership or non-membership in any labor organization, or any other characteristic protected under federal, state or local law. None of the questions in this application are intended to elicit information regarding protected characteristics, nor imply any limitations, preference or discrimination.
Applicant Statement & Submission
I certify that all information I have provided in order to apply for secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, Connections, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not lawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable federal, state and local laws.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply by filling out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Executive Director of Connections.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete and I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect will be sufficient cause to: (1) eliminate me from further consideration for employment or (2) may result in my immediate discharge from Connections, whenever it is discovered.
YOU ARE UNABLE TO SUBMIT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.*

YES, I CERTIFY THAT I HAVE READ, FULLY UNDERSTAND AND ACCEPT ALL TERMS OF THE FOREGOING APPLICANT STATEMENT.NO, I HAVE NOT READ THE ABOVE STATEMENT. I REALIZE THAT UNTIL I HAVE READ AND ACCEPT THE ABOVE STATEMENT THAT I AM UNABLE TO SUBMIT THIS APPLICATION.
PLEASE NOTE: Upon submitting this application, you should receive an email response letting you know that the application was received. If you did not receive this email, your application may not have been submitted. If this is the case, please check to make sure you have not missed any mandatory questions above in the application. If you do not receive this response email, please call us at 701-532-1145 to verify that we have received the application.
Enter the message as it's shown to prove you are a human.*
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