Employment Application - Big Bend Cares

Step 1 of 5

20%

Position(s) Applied for(Required)

Date of Application(Required)

Month

Day

Year

Referral Source(Required)

Agency Website

College/University Career Center

Job Fair

Other Job Sites (e.g. Indeed)

Professional Networking (e.g. LinkedIn)

Referral (relative, coworker, friend, etc.)

Search Engine (e.g. Google, IE, Bing, etc.)

Social Media (Facebook, Instagram, or Twitter)

Current Employee

Employment Agency

Walk-in

Other

Referred by:

Name(Required)

First Middle Last

Preferred First Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Contact Telephone Number(Required)

Contact Email Address

Have you ever applied here before?(Required)

Yes

If Yes, give date

Month

Day

Year

Have you ever worked here before?(Required)

Yes

If Yes, from

Month

Day

Year

Month

Day

Year

Are you legally eligible for employment in this country?(Required)

(Proof of U.S. Citizenship or immigration status will be required upon employment.)

Yes

Date available for work(Required)

Month

Day

Year

Type of employment desired(Required)

Full Time

Part Time

Temporary

Seasonal

Educational Co-Op

Are you on lay-off and subject to recall?(Required)

Yes

Will you travel if the job requires it?(Required)

Yes

Are you able to meet the attendance requirements of the position?(Required)

Yes

Will you work overtime if required?(Required)

Yes

Have you ever been bonded?(Required)

Yes

Have you been convicted of a felony, had adjudication withheld, pled nolo contender, or entered into any other pleas in the last seven (7) years?(Required)

(Such a conviction may be relevant if job-related, but does not bar you from employment.)

Yes

If Yes, please explain

Have you been disciplined or terminated for engaging in harassing or discriminating behavior?(Required)

Yes

If Yes, please explain

Driver's License Number (if required by job)

State

List your last four (4) employers, assignments or volunteer activities, starting with the most recent and working backwards in time, including military experience. Explain any gaps in employment in comments section below.

Employer 1

Company Name

Company Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Job Title

Immediate Supervisor Name and Title

Supervisor Phone Number

Currently working here?

Yes

May we contact for reference?

Yes

Dates Employed From

Month

Day

Year

Month

Day

Year

Hourly Rate/Salary

Per

Summarize the nature of the work performed and job responsibilities

Reason for Leaving

Employer 2

Company Name

Company Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Job Title

Immediate Supervisor Name and Title

Supervisor Phone Number

Currently working here?

Yes

May we contact for reference?

Yes

Dates Employed From

Month

Day

Year

Month

Day

Year

Hourly Rate/Salary

Per

Summarize the nature of the work performed and job responsibilities

Reason for Leaving

Employer 3

Company Name

Company Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Job Title

Immediate Supervisor Name and Title

Supervisor Phone Number

Currently working here?

Yes

May we contact for reference?

Yes

Dates Employed From

Month

Day

Year

Month

Day

Year

Hourly Rate/Salary

Per

Summarize the nature of the work performed and job responsibilities

Reason for Leaving

Employer 4

Company Name

Company Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Job Title

Immediate Supervisor Name and Title

Supervisor Phone Number

Currently working here?

Yes

May we contact for reference?

Yes

Dates Employed From

Month

Day

Year

Month

Day

Year

Hourly Rate/Salary

Per

Summarize the nature of the work performed and job responsibilities

Reason for Leaving

Comments (including explanation of any gaps in employment)

Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with our company.

Education History - Last School Attended

School Name

Area of Study

Did you graduate?

Yes

Degree Obtained

Graduation Date

Month

Day

Year

School Type

Highschool

College/University

Graduate School

Other

School Location

Second Last School Attended

School Name

Area of Study

Did you graduate?

Yes

Degree Obtained

Graduation Date

Month

Day

Year

School Type

Highschool

College/University

Graduate School

Other

School Location

Third Last School Attended

School Name

Area of Study

Did you graduate?

Yes

Degree Obtained

Graduation Date

MM slash DD slash YYYY

School Type

Highschool

College/University

Graduate School

Other

School Location

Give the names of three persons not related to you, whom you have known at least three (3) years.

Reference 1

Name(Required)

Email Address(Required)

Phone Number(Required)

Work, school, or personal reference?(Required)

Work

School

Personal

Other

Years Known(Required)

Relationship(Required)

Reference 2

Name(Required)

Email Address(Required)

Phone Number(Required)

Work, school, or personal reference?(Required)

Work

School

Personal

Other

Years Known(Required)

Relationship(Required)

Reference 3

Name(Required)

Email Address(Required)

Phone Number(Required)

Work, school, or personal reference?(Required)

Work

School

Personal

Other

Years Known(Required)

Relationship(Required)

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)

Organization

Office Held

List any additional information you would like us to consider.

Voluntary Affirmative Action Information

(Completion of information below is voluntary)

Although the following information is not mandatory, it is requested to aid the Big Bend Cares, Inc. in its commitment to Equal Employment Opportunity, Affirmative Action and to meet government record keeping, reporting and other legal requirements. This information is confidential and refusal to answer will not result in adverse treatment of any candidate. Your cooperation is appreciated.

Today's Date(Required)

Month

Day

Year

Legal Name(Required)

Last First Middle

Date of Birth

Month

Day

Year

As required, we comply with government regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated.

Please be advised that your survey is not a part of your official application for employment It is considered confidential information that will not be used in any hiring decision.

Select one:(Required)

Male

Female

I do not wish to answer

Race (select one):(Required)

Black or African American

White

American Indian/Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Two or More Races

I do not wish to answer

Ethnicity (select one):(Required)

Hispanic or Latino

Not Hispanic or Latino

I do not wish to answer

Veteran Information

(Completion of information below is voluntary)

Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era and qualified handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.

If you so wish to be identified, please check if any of the following are applicable:(Required)

Vietnam Era Veteran

Disabled Veteran

Individual with a Disability

I do not wish to answer

Not for interview purposes – To be filed separately from application. This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated by another federal law or regulation.

Upload Your Resume

Accepted file types: pdf, Max. file size: 128 MB.

Applicant Acknowledgement and Signature(Required)

I am aware and agree upon that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for employment and, if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I authorize the Agency to conduct an electronic screen of my background including queries on Internet search sites, such as Google, and social network sites, such as Facebook. I consent to the release of information about my past experiences, ability, employment history, and fitness for employment. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. The consent shall continue to be effective during my employment if I am hired. I understand that this application is current for only 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

I certify to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith.

I agree to the Applicant Acknowledgement

Type Full Legal Name(Required)

Applicant E-Signature: By typing my full name, I certify that I have read and agree with these statements.

Today's Date(Required)

Month

Day

Year