Job Application

Application for Employment

IMPORTANT: The Arc of the Piedmont prohibits discrimination against applicants on the basis of race, creed, color, religious opinion or affiliation, national origin, political affiliation, sex, age, physical or mental disability, sexual orientation, or veteran status, in accordance with applicable federal law, and complies with applicable state and local laws prohibiting discrimination in employment in each area where it has operations. The Arc of the Piedmont also provides reasonable accommodations to qualified individuals with disabilities in accordance with the requirements of the Americans with Disabilities Act and applicable state and local laws. Applicants requiring a reasonable accommodation in order to participate in the interview process are requested to contact Human Resources in order to arrange such accommodation.

I am interested in... *Full-timePart-timeRelief (as-needed or PRN staff)

I can work in... *CharlottesvilleCrozetNelson/LovingstonLouisa

Personal Data

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Phone *

Have you worked here before? *YesNo

If yes, please provide dates and position. *

Are you authorized to work for all employers in the United States on a full-time basis, or only for your current employer? *All employersCurrent employer onlyFederal laws require that employers hire only individuals who are authorized to be lawfully employed in the United States. To comply with these laws, all offers of employment are subject to verification of each applicant’s identity and employment authorization. You will have to submit those documents that are required by law to verify your identification and employment authorization upon employment. Please understand that State licensing regulations require staff who provide direct support to our clients be at least 18 years of age or older.

Are you at least 18 years of age? *YesNo

Do you have any relatives employed by The Arc? *YesNo

Have you ever been convicted of a crime? *YesNoIMPORTANT: The Arc does conduct background checks. Non-disclosure will result in termination of employment. Do not include convictions which have been sealed or expunged.

If yes, state the nature of the offense, when, where and disposition: *

Do you have a valid Driver's License? *YesNo

Do you have a vehicle? *YesNo

Please list any moving violations (type and date) from the past 5 years (approximate dates are fine).

How did you learn about our job opportunities? *

If referred by an Arc employee, please type name.

Educational History

Education *

Name of High School *

City and State of High School

Name of College

Number of years completed

Major

Degree?YesNo

Other education or technical training

Skills/Experience

Are you able to type? *YesNo

Summarize other special skills and qualifications relating to the position.

Summarize any specific work, family or volunteer experience related to the position.

Why do you want to work with adults with intellectual disabilities and related disabilities?

Employment Record

Employer

Name of Company *

Type of Business

Beginning of Employment *

End of Employment *

Position *

Name & Title of Immediate Supervisor *

Reason for Leaving *

Phone

Address of Company

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

May we contact this employer for a reference? *YesNo

Professional References

List three professional references who have knowledge of your qualifications. These should not be family nor personal friends.

References

First and Last Name *

Title/Relationship *

Name of Company *

Phone Number

Email Address

May we contact this reference? *YesNo

Upload Resume (optional)

No file chosen

Pre-Employment Statement

Please read carefully before signing
I understand and agree that:
The information on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification of refusal of employment, or if employed, termination from The Arc of the Piedmont’s employ.
Any offer of employment I may receive from The Arc of the Piedmont is contingent upon my successful completion of the agency’s total pre-employment screening process, including the agency’s receiving reference that it considers satisfactory, and my satisfactory completion of any post offer pre-employment medical examination that the agency may require. I also agree, if employed, to submit to a medical examination at any time at the agency’s request. I further agree, if employed, to submit to any training and testing required by the Department of Behavioral Health & Developmental Services as part of the agency’s licensing requirements. I hereby consent to having the results of any post-offer pre-employment or post-employment examination or testing I may be required to take disclosed to the Department of Behavioral Health & Developmental Services as part of the agency’s licensing requirements.
I understand that as a condition of employment, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of the Executive Director. I hereby consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to the Executive Director or his/her designee.
I authorize and request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for termination of my employment, work performance abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information.
In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the agency and understand that my employment and compensation can be terminated with or without cause or notice, at any time, at the option of either the company or myself. I further understand that no manager or representative of the agency, other than the Executive Director or Board President, has any authority to enter into any agreement with my for employment for any specified period of time or to make any agreement different from or contract to the foregoing. I further understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me and the Executive Director or Board President.

Date *

Signature *