Position Applied For:                                                                                                                                                                                                    

Residential Support
Vocational Consultant
Other: Please enter below:

                Other position:

Date of Application:

Please provide the following contact information:

First Name
Middle Initial
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Ph, Cell Ph
E-mail

Have you ever filed an application with VCS before?

Yes No

Have you ever been employed with VCS before?

Yes No

Do any of your friends or relatives work for VCS?

Yes No

            If YES, please provide name:

Are you currently employed?

Yes No

May we contact your present employer?

Yes No

Are you prevented from lawfully becoming employed in this country due to immigration status?

Yes No       

Proof of citizenship or immigration status will be required upon employment.

Date available for work:

What is your desired salary range?

Are you available to work: (select one or more)

Full time
Part time
Relief work
Temporary

Please indicate preferences: (select one or more)

Mornings
Afternoons
Evenings
Graveyard

Have you ever been convicted of a felony? A conviction record may not necessarily eliminate your candidacy for employment. 

Yes No

(Proof of a cleared background check is a condition of continued employment.)

DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the activities involved in the job or occupation for which you have applied? (A review of the activities in such a job or occupation has been given.)

Yes No

Yes No

High School
City
Subjects Studied
Years Completed
Diploma or Degree

 

College
City
Subjects Studied
Years Completed
Diploma or Degree

 

Grad or Prof
City
Subjects Studied
Years Completed
Diploma or Degree

 

Other
City
Subjects Studied
Years Completed
Diploma or Degree

WORK EXPERIENCE

Start with your present or last job; include any job-related military service assignments and volunteer activities. (You may exclude organizations, which may indicate race, color, religion, gender, national origin, disabilities or other protected status.)

Current or most recent job:

Job title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
Supervisor
Starting salary
Ending salary
worked from
to
reason for leaving
May we contact?	YES NO

Job prior to one listed above:

Job Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
Supervisor
Starting salary
Ending salary
worked from
to
reason for leaving
May we contact?	YES NO

Job prior to one listed above:

Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
Supervisor
Starting salary
Ending salary
worked from
to
reason for leaving
May we contact?	YES NO

Describe any specialized training, experience, apprenticeship, skills and extra-curricular activities:

List professional, trade, business or civic activities and offices held:

Additional information:

PERSONAL / PROFESSIONAL REFERENCES

Do not include family members or past supervisors.

Reference 1

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Occupation
Work Phone
Home Phone

Reference 2

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Occupation
Work Phone
Home Phone

Reference 3

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Occupation
Work Phone
Home Phone

DECLARATIONS AND ACKNOWLEDGMENTS:

I understand that the receipt of this application does not imply that I will be employed.

Yes No

I declare that all statements and answers in this application are true and complete and agree that any untrue or misleading answer, omission concealment or failure to answer any question fully, completely and accurately will be grounds for terminating my employment, regardless of when it is discovered.

Yes No

I authorize Village Community Services (VCS) or an agent of VCS to investigate my references, to review my former employment record and to keep and preserve records of such investigations. Additionally, I release VCS and all other parties from liability for any damage that may result from, or is related to, the furnishing of information to Village Community Services.

Yes No

If employed, I agree to read and comply with Company rules, regulations and policies.

Yes No

If employed, I agree that upon termination of employment, I will return all agency property and records in my possession.

Yes No

 

My application is   NOT READY to submit READY to submit