Pentecostal

EMPLOYMENT APPLICATION



Alternative Services -Connecticut, Inc. is an equal opportunity employer, dedicated to a policy of nondiscrimination in employment, training, scheduling, transfer, promotion, payment or discipline on any basis including race, color, national origin, ancestry, religion, sex, age, marital status, veteran status, sexual orientation, present or past history of mentaldisorder, mental retardation, learning disability or physical disability including blindness, sexual orientation and genetic information or any other protected class status.

Please answer all questions fully and accurately even if a resume or other materials are attached. This application may be rejected if answers are vague or incomplete.
Date:_____________________

Name: ____________________________________________________________________________________ (Last) (First) (Middle)


Address:___________________________________________________________________________________
(Street) (Apt. #)

Telephone #: ( )____________________
(City, State, Zip Code)

Other Telephone #: ( ) Are you 18 years old or older? ____ Yes ____ No

Are youeither a U.S. Citizen or legally eligible for employment in this country? ____ Yes ____ No

SSN: ____________________________________ Date available for work: ____________________________________

Position for which you are applying for: ____ FT ____ PT ____On-Call

List hours & days are you not available:_____________________________________________________________

How did you learn of ASI-CT? Referral Name: _______________________________________________

Have you ever been employed by, or previously applied to, this Agency? _____ Yes ____ No
If Yes, when and indicate if employed under a different name? ____________________________________________

Do you have any relatives who currentlywork for this Agency? ____ Yes ____ No

If Yes, who? __________________________________________________________

Do you have a valid driver’s license? _____Yes ____ No Do you have a Public Service License? ____ Yes ____ No

We are licensed to provide adult care for 24 hours a day, 7 days a week, 52 weeks a year. Working overtime hours, per the specification of our laborcontract, is expected for continued employment. Are you able to meet this requirement?
_____ Yes _____ No

Are you able to perform all activities and essential functions of the position (on the enclosed job description) for which you are applying with or without an accommodation? ____ Yes ____ No

Have you ever been convicted ** of a felony crime or misdemeanor? ____ Yes ____ No If Yes,on the back of this application, please list the date and place of the offense, the charge, circumstances and the disposition. (The existence of a criminal record does not constitute an automatic bar to employment). ** See Application Addendum disclaimer.






EMPLOYMENT HISTORY


Please list your employment history. Begin with your present or most recent employment, show allemployment including full, part-time and summer positions. This section must be completed regardless of a resume.




Name of Present or Last Employer: Name of Supervisor:

May we contact (only if presently employed _____ Yes ____ No*

Address: Phone Number:


Job Title: Employment Dates:
From (month/year) To (month/year)...