Employment Form

APPLICATION FOR EMPLOYMENT

CALMRA, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, CALMRA, Inc. complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

* Required Information

Referred by (please print the staff name here) *

Position(s) of interest *

Date *

Applicant’s First Name *

Middle Name

Last Name *

Present Street Address *

Apt. Number

Cell Phone Number

City *

State *

Zip Code

Home Phone Number *

Email Address *

Work/Other Phone Number

Are you 18 years of age or older?

Yes

Are you authorized to work in the United States of America?

Yes

Do you have a valid U.S. driver’s license?

Yes

Driver’s license number

State

Are there any limitations to the hours which you can work?

Yes

Please detail

What is your anticipated salary with CALMRA, Inc.?

Per

Hour

Year

Have you previously applied with CALMRA, Inc.?

Yes

When?

Have you ever been employed by CALMRA, Inc.?

Yes

When?

Do you have any relatives employed by CALMRA, Inc.?

Yes

Please list

Have you ever been dismissed, terminated, or asked to resign by a previous employer?

Yes

Please explain

EDUCATION BACKGROUND

HIGH SCHOOL

Did You Graduate?

Yes

Degree/Major

School Name

Location (City/State)

TRADE/BUSINESS

Did You Graduate?

Yes

Degree/Major

School Name

Location (City/State)

COLLEGE/UNIVERSITY

Did You Graduate?

Yes

Degree/Major

School Name

Location (City/State)

GRADUATE/OTHER

Did You Graduate?

Yes

Degree/Major

School Name

Location (City/State)

CURRENT EMPLOYMENT

Present Employer *

Position Title

Street Address

Start Date

City

State

Zip Code

Starting Salary

Phone Number

Supervisor

Current Salary

Description of responsibilities

May we contact?

Yes

PREVIOUS EMPLOYMENT HISTORY

**Start with most recent employer first. Please list up to 3 previous employers, including any international work.

Employer

Position Title

Street Address

City

State

Zip Code

Start Date

End Date

Starting Salary

Last Salary

Phone Number (or email if outside of U.S)

Supervisor

Description of responsibilities

Reason for leaving

Employer

Position Title

Street Address

City

State

Zip Code

Start Date

End Date

Starting Salary

Last Salary

Phone Number (or email if outside of U.S)

Supervisor

Description of responsibilities

Reason for leaving

Employer

Position Title

Street Address

City

State

Zip Code

Start Date

End Date

Starting Salary

Last Salary

Phone Number (or email if outside of U.S)

Supervisor

Description of responsibilities

Reason for leaving

Please explain any signaicant gaps in employment (i.e. for school, caring for a child, etc.)

EMPLOYMENT REFERENCES

Please list three current or past supervisors, managers, co-workers, etc.

Name (First and Last)

Relationship to applicant

Name of Business/Employer

Contact Number(s)

Name (First and Last)

Relationship to applicant

Name of Business/Employer

Contact Number(s)

Name (First and Last)

Relationship to applicant

Name of Business/Employer

Contact Number(s)

Have you ever worked with developmental disabilities?

Yes

Please explain briefly:

What accommodations, if any, are necessary for you to fulfill the job requirements of the position for which you are applying?

Additional comments by applicant, if desired:

AGREEMENT

Read carefully before signing this application.

I hereby affirm that the information provided on this application and/or accompanying resume is true and complete to the best of my knowledge.

• I am aware that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date

• I understand that if hired, my employment can be terminated with or without notice at any time, for any reason.

• I understand that no management official is authorized to make any assurance or promise of continued employment and that any such pledge or agreement related to continued employment must be in writing and signed by the Executive Director.
• It is the policy of CALMRA, Inc. that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the work place.

• I understand that if hired, I must be drug and alcohol free when I report to work.

• I also understand that CALMRA may, at any time, institute drug testing, and that all employees (full-time and part-time) may be required to report for drug testing according to an established schedule.

CONSENT FOR RELEASE OF INFORMATION

• I authorize employers (past and present), schools and other individuals or organizations named in this application and/or accompanying resume to provide any relevant information that may be required to arrive at an employment decision.

• I give permission for information regarding my work performance to be released to CALMRA, Inc., and I understand that this information will be treated as confidential and will not be divulged to me.

• I authorize CALMRA, Inc. to seek any disclosable information regarding me from the Central Registry of Abuse, which is maintained by the Office of Licensing Certification Programs.

• I also authorize the Office of Licensing Certification Programs to release the above mentioned information to CALMRA, Inc.

• A photocopy or fax of the release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature.

Employee Signature

Clear

Date