Position Applied For:

Residential Support  Vocational Consultant Other:

Please provide the following contact information:

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:

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , 2010 2011

What is your desired salary range?

    $     per - hour month year

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.)

 

Notice to Applicants:

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

 

EDUCATION

Do you have a High School Diploma or GED?

Yes No

High School
City
Subjects Studied
Number of Years Completed
Diploma or Degree

 

College
City
Subjects Studied
Number of Years Completed
Diploma or Degree

 

Grad or Prof
City
Subjects Studied
Number of Years Completed
Diploma or Degree

 

Other
City
Subjects Studied
Number of 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
Address
City,State,ZIP
Phone
Supervisor
Starting salary	$ per - hour month year
Ending salary	$ per - hour month year
worked from	- January February March April May June July August September October November December - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , - 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940
to	- January February March April May June July August September October November December - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , - 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940   currently employed
reason for leaving
May we contact?	- YES NO

Job prior to one listed above:

Job Title
Organization
Address
City,State,ZIP
Phone
Supervisor
Starting salary	$ per - hour month year
Ending salary	$ per - hour month year
worked from	- January February March April May June July August September October November December - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , - 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940
to	- January February March April May June July August September October November December - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , - 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 currently employed
reason for leaving
May we contact?	- YES NO

Job prior to one listed above:

Title
Organization
Address
City,State,ZIP
Phone
Supervisor
Starting salary	$ per - hour month year
Ending salary	$ per - hour month year
worked from	- January February March April May June July August September October November December - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , - 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940
to	- January February March April May June July August September October November December - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , - 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 currently employed
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

Name
Address
City, State, ZIP
Occupation
Phone

Reference 2

Name
Address
City, State, ZIP
Occupation
Phone

Reference 3

Name
Address
City, State, ZIP
Occupation
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

Please review application before submitting.

My application is                  NOT READY READY     to submit.

The following user information is saved upon form submission:
Remote Computer Name, Browser type, Username.
This information is not used for any purpose other than to
track those who choose to submit forms for illegitimate reasons.