5283 Neff Lake Rd. Brooksville, FL 34601
Tele: 352-544-2322 Fax: 352-544-2325  

 

 

*  Required area

* Date:

* Full Name:

* Address:

* City, State, Zip:

* Are you 18 Years of age or older?  Yes   No   If under 18, please state your age

 

* Home Phone:

 

* Cell Phone:

* E-mail Address:  

* Positions Applied for:

* Salary Desired:

* Hours You Can Work:


 Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

 

* Can you Work?  Full Time Part Time    Full or Part Time

 

* When Can You Begin Work:

* Have you ever been employed by us?  Yes   No   If yes when and what location

 

* Where did you go to School?

Type of School

Name of School and Complete Mailing Address

No. of Years Completed

Major or Degree
High School
College/Trade
Professional
Other

 

* Have you ever been convicted of a crime other than a minor traffic violation or entered a plea of guilty or nolo contendre  ( no contest)? 

 Yes     No

If yes please explain.  

* Do you have a Driver License?   Yes      No State

* Have you had any accidents in the past 3 years?  Yes   No       How many?   

* Have you had any moving violations in the past 3 years?  Yes    No        How many?  

 

Previous Employment (5 Year Work History)

1.

* Name of Employer:
 

* Name of Last Supervisor:


 Date of Employment:

* From:                      * To:

Salary:

* From:                      * To:

*   Complete Address:

*   Phone Number:

*   Last Job Title:

*   Reason For Leaving (Please be Specific):

*   List job duties:

May we contact your employer?  Yes      No 

 

2.

* Name of Employer:
 

* Name of Last Supervisor:


 Date of Employment:

* From:                      * To:

Salary:

* From:                      * To:

*   Complete Address:

*   Phone Number:

*   Last Job Title:

*   Reason For Leaving (Please be Specific):

*   List job duties:

May we contact your employer?  Yes      No 

 

3.

* Name of Employer:
 

* Name of Last Supervisor:


 Date of Employment:

* From:                      * To:

Salary:

* From:                      * To:

*   Complete Address:

*   Phone Number:

*   Last Job Title:

*   Reason For Leaving (Please be Specific):

*   List job duties:

May we contact your employer?  Yes      No 

 

4.

* Name of Employer:
 

* Name of Last Supervisor:


 Date of Employment:

* From:                      * To:

Salary:

* From:                      * To:

*   Complete Address:

*   Phone Number:

*   Last Job Title:

*   Reason For Leaving (Please be Specific):

*   List job duties:

May we contact your employer?  Yes      No 

 

5.

* Name of Employer:
 

* Name of Last Supervisor:


 Date of Employment:

* From:                      * To:

Salary:

* From:                      * To:

*   Complete Address:

*   Phone Number:

*   Last Job Title:

*   Reason For Leaving (Please be Specific):

*   List job duties:

May we contact your employer?  Yes      No 

 

*   Skills:

*   Typing:

 

*   Computer:       PC     MAC      Both

 

*   Applications: (List all that apply)

*   Others Skills:

 

Please list references other than relatives and previous employers
Name
Position
Company
Telephone

 

Please list references other than relatives and previous employers

Name
Position
Company
Telephone

 

*   Additional Comments:

 

Applicant Statement

 
Notice to Applicants:


The Arc Nature Coast, Inc. complies with the American With Disabilities Act of 1990. During the interview process, you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo medical examination. If required, entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information will be kept confidential.


This application for employment will remain active for 30 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.


If this application for employment is accepted, I understand that employment is not for any guaranteed term and may be terminated by The Arc Nature Coast, Inc. or the employee at any time for any reason. It is further understood that this "at will" employment relationship may not be changed by any written document, verbal statement, or conduct unless such change is specifically acknowledged in writing by the Executive Director in a written document titled "Employment Contract", and which specifically states the employee is not an At-Will employee.


 I authorize The Arc Nature Coast, Inc. to investigate my background and all statements contained in this application for employment as may be necessary to arrive at an employment decision, including the contacting of the employers, educational institutions, and persons listed previously, as well as law enforcement agencies, credit institutions, or other persons having personal knowledge about me.


I hereby release and hold harmless my current and former employers, educational institutions, and persons or organizations named on this application or accompanying resume from all liability on account of furnishings such information to The Arc Nature Coast, Inc.


I consent to a medical examination and the collection of blood and/or urine samples, as requested for the purpose of determining the presence of alcohol and/or drugs. I furthermore authorize the release of all medical information obtained during the examination and testing procedure to The Arc Nature Coast, Inc. I understand that a Drug Free Workplace Program is in effect and that a positive result may be grounds for termination.


I understand that if I am hired I will be subject to a 90 day probationary period.


I certify that all information contained in this application is correct to the best of my knowledge.
 

 

Applicant's Signature:

                    

Date:

 

Please print application before submitting and bring to interview if called.