Application Application for Employment For Office Use Only 1st Choice: ______________________ Contact Date:__________________ Interview Date/Time:_____________________ 2nd Choice: _____________________ Contact Date:__________________ Interview Date/Time:_____________________ 3rd Choice: _____________________ Contact Date:__________________ Interview Date/Time:______________________ Application Received: _______________________ HR Approval:_______________________ Date:_____________________ Last Name: * First Name * Daytime Phone Number * Cell Phone Number * Physical Address * City * State * Zip Code * Mailing Address * City * State * Zip Code * E-mail Address * Position applying for: Any Position Children Services Adult Day Services Arkadelphia Waiver Community Waiver Residential Waiver Support Services (Transportation & Food Services Administration Nursing Maintenance SkyROCit How did you hear about this position? * RadioOnlineFacebook/TwitterNewspaperClassifiedsWalk-inReferralJob Fair Did a current employee refer you? * Yes No If yes, who? Days available to work: (check all that apply) * No Preference Monday-Friday Sunday-Thursday Saturday - Sunday Friday - Saturday Friday - Sunday How many hours can you work weekly? * What time can you work Monday-Friday? (check all that apply) * 8a-4p 7a-3p 6a-2p 3p-11p 11p-7a Any Split Shift None What time can you work Sunday-Thursday? (check all that apply) 4p-9p 3p-11p 11p-7a Any None What time can you work on Weekends? (check all that apply) 7a-11p 7a-3p 3p-11p 11p-7a Any None Were you previously employed by us? * Yes No If yes, when? If application is considered favorable, what date will you be available to work? * Are you under 21 years of age? * Yes No Are you eligible to be bonded? * Yes No If offered employment, can identification & authorization to work in the U.S be provided? * Yes No Have you been arrested and/or convicted of any felony crime? * Yes No Have you been arrested and/or convicted of any crime involving theft? * Yes No Have you been dischared from any employment for theft/dishonesty/fraud? * Yes No Have you been arrested and/or convicted of any crime involving alcohol or drugs? * Yes No Have you been arrested and/or convicted of any crime involving sexual abuse? * Yes No Have you been convicted of any crime involving battery or assault? * Yes No Have you been denied parental, custodial, or visitation rights as a result of neglect or abuse of a child or adult? * Yes No If answered "yes" to previous 7 questions, please explain. Note: Conviction record will not necessarily bar employment. Factors such as age and time of offense, seriousness and nature of the violation, and the relationship of the crime to the position for which you are applying will be considered. GED? * Yes No N/A School Name: School Address (City/State) High School - Graduated? * Yes No N/A School Name: School Address (City/State) College - Graduated? * Yes No N/A School Name: School Address (City/State) Business/Trade School? * Yes No N/A School Name: School Address (City/State) Do you speak a language other than English? * Yes No Read that language? * Yes No Write that language? * Yes No What is the language? What specialized training and/or apprenticeship have you had? * What military training have you had? * What clubs or professional associations have you been a part of? * What extra-curricular activities are you involved in? * Educational Reference: Name Address City, State, Zip Code Phone Number Class (year graduated) Work History List in order starting with present employer. You must show the past 10 years of employment history. this section must be completed even if you are submitting a resume. _______________ PRESENT Employer Name: Address City, State, Zip Code Supervisor Name Supervisor Address Supervisor City, State, Zip Code Phone Number Date Employment Began Date Employment Ended Reason For Leaving Job Title/Duties PAST Employer Address City, State, Zip Code Supervisor Name Supervisor Address Supervisor City, State, Zip Code Phone Number Date Employment Began Date Employment Ended Reason For Leaving Job Title/Duties PAST Employer Address City, State, Zip Code Supervisor Name Supervisor Address Supervisor City, State, Zip Code Phone Number Date Employment Began Date Employment Ended Reason For Leaving Job Title/Duties PAST Employer Address City, State, Zip Code Supervisor Name Supervisor Address Supervisor City, State, Zip Code Phone Number Date Employment Began Date Employment Ended Reason For Leaving Job Title/Duties PAST Employer Address City, State, Zip Code Supervisor Name Supervisor Address Supervisor City, State, Zip Code Phone Number Date Employment Began Date Employment Ended Reason For Leaving Job Title/Duties PAST Employer Address City, State, Zip Code Supervisor Name Supervisor Address Supervisor City, State, Zip Code Phone Number Date Employment Began Date Employment Ended Reason For Leaving Job Title/Duties PAST Employer Address City, State, Zip Code Supervisor Name Supervisor Address Supervisor City, State, Zip Code Phone Number Date Employment Began Date Employment Ended Reason For Leaving Job Title/Duties Employment Reference: (Other than immediate supervisor) Name Address City, State, Zip Code Phone number Relationship Employment Reference: (Other than immediate supervisor) Name Address City, State, Zip Code Phone number Relationship Employment Reference: (Other than immediate supervisor) Name Address City, State, Zip Code Phone number Relationship I hereby give permission to contact the employers and/or references listed above concerning my prior education and/or work experience. * Agree Disagree If there is a particular employer(s) you do not wish us to contact, please indicate which ones and reason why. NEPOTISM Employees of ROC/OH/PNC avoid any actions that may be construed as nepotism and refrain from activities that would constitute a conflict of interest. The employment of relatives can cause various problems, including charges of favoritism conflicts of interest, family discord and scheduling conflicts that work to the disadvantage of both ROc/OH/PNC and its employees. This policy applies to all ROC/OH/PNC positions, full-time and part-time, regular and temporary; therefore, it is the policy of ROC/OH/PNC not to hire immediate family members if it creates: Supervisor/subordinate relationship with a family member in same component or service area; this includes the following relationships: 1. husband or wife 2. son or daughter (in-law) 3. step relationships 4. father or mother (in law) 5. uncle or aunt 6. brother or sisiter (in-law) 6. grandmother or grandfather (in-law) 8. Grandchild 9. cousins 9. cousins 10. nieces or nephews 11. Similar relationships (i.e. significant others, godparents, etc.) Do you have any family members that currently work for ROC? * Yes No Family Members Name Location of Work Position What is your relationship? Family Members Name Location of Work Position What is your relationship? Family Members Name Location of Work Position What is your relationship? I have answered all questions completely and to the best of my knowledge. I also understand that I will be required to provide a copy of my driver’s license, social security card and high school diploma, GED, and/or college certification. Therefore, I understand that providing this information is a condition of employment. Rainbow of Challenges, Inc. is a drug-free and alcohol-free workplace. I understand that ROC is an employment at will agency and relationship will be voluntary and I or ROC can terminate the relationship at will, with or without cause at any time. By submission of this form, I hereby do declare that, to the best of my knowledge and my ability, the information on this application is true and factual. I understand that intentional false statements could lead to my dismissal as an employee or rejection as an applicant. I also understand any position with this organization requires background checks and security clearance prior to employment, and that failure to meet these requirements may lead to my rejection as an applicant for any position. * I Agree Disagree Email Website/URL If you are human, leave this field blank. Δ
