Employment Application

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Last Name (Required)

First Name (Required)

Middle Name

Street Address (Required)

City (Required)

State (Required)

Zip (Required)

Telephone # (Required)

Cellular/Other Phone #

E-mail Address (Required)

Position(s) applied for (Required)

Locations Applied for (Required)

What is your desired salary range or hourly rate of pay? (Required)
Type of employment desired: (Required)
Full-TimePart-Time

Employment History

Starting with your most recent employer, provide the following information.

Employer (Required)

Telephone # (Required)

Street Address (Required)

City (Required)

State (Required)

Starting job title/final job title (Required)

Why did you leave? (Required)

May we contact for reference?
YesNoLater

Dates Employed: (Required)

Summarize the type of work performed and job responsibilities. (Required)

Employer

Telephone #

Street Address

City

State

Starting job title/final job title

Why did you leave?

May we contact for reference?
YesNoLater

Dates Employed:

Summarize the type of work performed and job responsibilities.

Employer

Telephone #

Street Address

City

State

Starting job title/final job title

Why did you leave?

May we contact for reference?
YesNoLater

Dates Employed:

Summarize the type of work performed and job responsibilities.

Employer

Telephone #

Street Address

City

State

Starting job title/final job title

Why did you leave?

May we contact for reference?
YesNoLater

Dates Employed:

Summarize the type of work performed and job responsibilities.

Explain any gaps in your employment, other than those due to personal illness, injury or disability. Please type N/A if there are no gaps in your employment. (Required)

If not addressed on previous page, have you ever been fired or asked to resign from a job? (Required)

YesNo

If yes, please explain - otherwise please type N/A: (Required)

Skills and Qualifications

Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying: (Required)

Are you currently CPR certified/provide proof of certification? (Required)

YesNo

Computer Skills (Check appropriate boxes. Include software titles and years of experience.) (Required)

Word ProcessingSpreadsheetPresentationE-mailInternetOther

Educational Background

Starting with your most recent school attended, provide the following information.


School (include City and State) (Required)
Years
Completed (Required)

Completed (Required)
GPA
Class Rank (Required)

Major/Minor (Required)
DiplomaGEDDegreeCertificationOther
DiplomaGEDDegreeCertificationOther
DiplomaGEDDegreeCertificationOther
DiplomaGEDDegreeCertificationOther

References

List names and telephone numbers of three business/work references who are not related to you.

Name (Required)
Title (Required)
Relationship to You (Required)
Telephone (Required)
E-mail (Required)
# of Years Known (Required)

Social Security Number

We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.

SS# (Required)

Related Information

To what job-related organizations (professional, trade, etc.) do you belong?

Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

Organization
Offices Held

List special accomplishments, publications, awards, etc.

Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.

Application Statement

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the right to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

Company policy prohibits unlawful discrimination based on race, religion, (all aspects of religious belief, observances, and practices including religious dress and grooming practices), color, national origin, ancestry, sex, (including pregnancy, child birth, breastfeeding, or related medical conditions), gender, gender identity, gender expression, actual or perceived sexual orientation, marital status, military and veteran status, civil air patrol status age, physical or mental disability, genetic information, or medical condition, except where physical fitness is a valid occupational qualification or any other consideration made unlawful by federal, state, or local laws. For purposes of this policy, discrimination on the basis of “national origin” also includes discrimination against an individual because of their primary language or because that person holds or presents the California Driver’s License issued to those who cannot document their lawful presence in the United States. An applicant’s or employee’s immigration status will not be considered for any Company employment purpose except as necessary to comply with federal, state or local laws. California law also prohibits discrimination against individuals providing services in the workplace pursuant to a contract, unpaid interns, and volunteers on the basis of actual or perceived race, color, creed, religion, sex, physical, or mental disability, genetic information or age. This commitment applies to all persons involved in the operations of the Company and prohibits unlawful discrimination by any employee of the company, including supervisors and co-workers. All such discrimination is unlawful.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant (Required)

Date

Job Applicant Consent

To Submit to Drug and/or Alcohol Testing As a Condition of Employment

I hereby consent and agree to drug and/or alcohol testing as a condition of employment by the ARC Fresno/Madera Counties, and/or its subsidiaries and/or affiliates (collectively referred to as "the Agency").

I further understand and acknowledge that:

  1. The Agency will pay the cost of all required drug and/or alcohol tests;
  2. The test results will be released to the Agency, and its representatives are authorized to receive, request, and transmit such information;
  3. The test results may be used by the Agency in determining any adverse employment action that may be taken against me, including denial or termination of employment; and
  4. I have the right to refuse to submit to such testing, but understand that refusal to submit to, or to cooperate with, such testing shall be considered a decision on my part not to be considered for employment with the Agency, and will result in denial of employment.

I further agree that the Agency has made no representations, inducements, or statements, other than those in writing, about the testing, and that I consent to be tested.

Job Applicant Signature (Required)

Date

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