Career Opportunities Form

Date of Application:

First: *

Middle:

Last: *

Address *

City:

State:

Zip Code:

Social Security Number:

Date of Birth:

Cell Phone Number: *

Home Phone Number: *

Email:*

Position Sought:

Paid Rate Requested:

Will you accept full-time work?:

Yes

No

Will you accept part-time work?:

Yes

No

Will you work all shifts including overtime?:

Yes

No

Date available:

Are you able to prove that you are at least 16 years of age upon hire?:

Yes

No

Are you a U.S. citizen or have a legal right to be employed in the U.S.?

Yes

No

Proof is required:

Do you have a position with another employer that would continue if employed by us?

Yes

No

Do you have Act 33/34 Clearance? (Applicant must provide copy of the clearance)

Yes

No

Do you have a valid driver’s license?

Yes

No

Driver License Number:

Do you have reliable transportation with valid insurance?

Yes

No

Have you ever been convicted of or plead guilty to a crime or any other offense, other than a traffic violation, which has not been expunged or sealed by the court? (Note: A yes answer does not automatically disqualify you from employment, since the nature of the offense, and date will be considered.)

Yes

No

(Criminal conviction will not necessarily disqualify you which you have applied, to help us evaluate please describe the offense below.) Yes, please explain:

May we contact your most recent employer?

Yes

No

Employer:

Phone Number:

Address:

Employed from:

To:

Position Title:

Wage/Salary:

Supervisor’s Name:

Reason for Leaving:

Nature of work performed and responsibilities:

Employer:

Phone Number:

Address:

Employed from:

To:

Position Title:

Wage/Salary:

Supervisor’s Name:

Reason for Leaving:

Nature of work performed and responsibilities:

Employer:

Phone Number:

Address:

Employed from:

To:

Position Title:

Wage/Salary:

Supervisor’s Name:

Reason for Leaving:

Nature of work performed and responsibilities:

Employer:

Phone Number:

Address:

Employed from:

To:

Position Title:

Wage/Salary:

Supervisor’s Name:

Reason for Leaving:

Nature of work performed and responsibilities:

Please explain any gaps in dates of employment:

Have you ever worked with or for any employees of This Generation Cares who would be willing to give you a good reference?

Yes

No

If so, who?

Name:

City, State, Zip:

Major/Course Of Study:

Highest Level Completed:

Degree:

Name:

City, State, Zip:

Major/Course Of Study:

Highest Level Completed:

Degree:

Name:

City, State, Zip:

Major/Course Of Study:

Highest Level Completed:

Degree:

Name:

City, State, Zip:

Major/Course Of Study:

Highest Level Completed:

Degree:

Name:

City, State, Zip:

Major/Course Of Study:

Highest Level Completed:

Degree:

Certifications: (Please list type and date)

Please list any special skills or training computer and software knowledge or equipment you can operate:

Are you a Veteran of the United States Military Service? Branch:

Does any medical condition prevent you from lifting? List:

Please state additional information (i.e, languages, etc) you would like us to consider:

PLEASE READ CAREFULLY

Special Employment Notice to Veterans w/ Disability, Vietnam Era Veterans and Individuals with Physical or Mental Disabilities

SpecialGovernment Contractors are subject to 38 USC 2012 of the Vietnam Era Veteran’s Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified veterans with a disability and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended which requires government qualified individuals with a disability.

If you are a veteran with a disability, or are a person with a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job to the best of your ability in a proper and safe manner.

This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment. If you wish to be identified, please sign below.

Person w/ Disability

Veteran w/ Disability

Vietnam Era Veteran

Applicant Signature:

Date:

Thank you for completing this application form and your interest in This Generation Cares.

I understand it is my responsibility to review the policy in the employee handbook and that I will be subject to future random and for cause testing and that this consent shall remain valid during my term of employment and is a term or condition of my employment. Consistent with the Policy, I may be requested by This Generation Cares to submit to a screening test for illegal drugs, illegally used drugs and /or alcohol which may include breath analysis, the collection of urine, hair and other necessary medical tests to determine the presence or use of alcohol, drugs, or controlled substances.

I hereby voluntarily consent to provide This Generation Cares with samples of urine and / or hair for such purpose at laboratories designated by This Generation Cares. I consent to having specimens tested at the selected laboratories. Further, I certify that the specimen collected from me will be mine and will not be adulterated or altered in any manner.

The tests will be used to detect the presence of the following substances, in addition to other substances for which This Generation Cares may be required to test for under Federal or State law.

Alcohol Cocaine Metabolites Methadone

Amphetamines Hallucinogens Phencyclidine (PCP)

Benzodiazepines Barbiturates Marijuana (Cannabinoid Metabolites)

Propoxyheene (Davon) Opiate Derivatives (Morphine, Codeine)

further understand that if my test indicates a confirmed positive for illegal drugs, I will not be considered for employment, or in the event I am an employee at the time of the test I may be subject to discipline including termination, in accordance with the Drug and Alcohol Policy. I will be given reasonable opportunity to explain confirmed positive test for substances other than illegal drugs. If I provide an unacceptable explanation I will be denied employment.

I understand that I may request a copy of any test taken, as part of the screening tests upon receipt of the results by This Generation Cares or from the laboratory.

I understand the results of these tests and other relevant medical information may be used for employment decisions. I hereby authorize the designated laboratory to release results to This Generation Cares. I further agree to hold This Generation Cares, its agents, officers and employees harmless from, and waive all claims existing and future for any, and all liability (including negligence) arising in connection with the testing for drugs and/or alcohol.

Applicant Signature:

Date:

Print Name: