THE ARC OF HAYWOOD COUNTY, INC., APPLICATION FOR EMPLOYMENT INSTRUCTION SHEET

Please take the time to fill out your application for employment in its entirety. These instructions are to assist you in the completion of this application.

PERSONAL

Furnish your mailing address and physical address as well as your home phone number, cell phone number or your business phone number where you can be reached also, please add your email address. Furnish your previous address if you have lived at your current address for less than five (5) years.

EDUCATION

Fill in the information as requested. A copy of your high school diploma or GED certificate is required.

WORK EXPERIENCE

List your current/most recent employer in the first box and proceed with listing the employers you have had prior to that in chronological order in the remaining boxes.

PROFESSIONAL REFERENCES

List five (5) professional references (not personal/relatives) in this section. It is imperative to furnish the names, titles and complete mailing addresses/email address and phone numbers.

AUTHORIZATION

Upon conditional offer of employment, please be advised that a criminal background screening will be processed for all prospective applicants.

In order for your application to be processed, your signature is required. Unsigned applications will not be processed. Motor Vehicle History Form and Pre-Employment Authorization Release forms are separate from the application but must be turned in as required by the State of North Carolina.

We thank you for taking the time to complete your application fully to avoid any delay that may arise from an incomplete application.

Training to be completed before Direct Care Services can be provided:

NCI plus – NC Interventions Plus
First Aid/CPR/AED
BBP – Bloodborne Pathogens
Cultural & Diversity Competency
Documentation Procedures
Electronic Documentation
Client Specific Competency

Innovations Services
Developmental/Intellectual Disabilities Orientation
Human Rights
Fire Safety
Vehicle Safety
Medication Administration
Incident Reporting

Name

First Name

Middle Name

Last Name

Phone (Include Area Code)

Home Phone

Cell Phone

Business Phone

Address

Street

Apt/Suite

City

Zip

State

Driver's License

State

Number

Other Information

Date Of Birth

Previous Address
If you have lived at a current address less than 5 years, please give previous address below

Previous Street

Previous Apt/Suite

Previous City

Previous Zip

Previous State

Previous Phone (Include Area Code)

Previous Home Phone

Previous Cell Phone

Previous Employment

Have you ever applied for employment with our agency?

What month/year did you last apply for employment with our agency?

Have you ever been employed by our agency?

When were you employed by our agency last?

Special Accomodations

Is there any reason you would be unable to perform the essential functions of the job with or without reasonable accommodation?

What accommodation would you require?

Eligibility

Position Desired

Pay Expected

Are you legally eligible for employment in the United States?

How long have you been a permanent resident of the State of North Carolina?

When will you be available to begin work?

Convictions
Be aware that a conviction/violation does not necessarily mean that you will not be hired for the position for which you are applying.

Have you ever been convicted of a FELONY, plead no contest or plead guilty to a lesser charge?

If you have had any convictions please list them here

Relationships

Are you a relative of an Arc Client?

If you are a relative of an Arc Client, please indicate who

Are you the legal guardian of an Arc Client?

If you are a legal guardian of an Arc Client, please indicate who

Education

High School

Name and Location

Course of Study

Number of Years Completed

Date of Graduation

Copy of Degree or Diploma Attached

College

Name and Location

Course of Study

Number of Years Completed

Date of Graduation

Copy of Degree or Diploma Attached

Other

Name and Location

Course of Study

Number of Years Completed

Date of Graduation

Copy of Degree or Diploma Attached

Membership in professional or civic organizations

Special training programs and seminars you have completed in the last five years. (Please List)

Attach Resume

Work Experience

Job #1

Employer

Address

Job Title

Supervisor's Name

Supervisor's Number

NO. supervised by you?

Date Employed (Month/Year)

Date Separated (Month/Year)

Full Time Years, Months

Part Time Years, Months

If part time, please list hours per week

Starting Salary

Ending Salary

Reason for Leaving?

Job #2

Employer

Address

Job Title

Supervisor's Name

Supervisor's Number

NO. supervised by you?

Date Employed (Month/Year)

Date Separated (Month/Year)

Full Time Years, Months

Part Time Years, Months

If part time, please list hours per week

Starting Salary

Ending Salary

Reason for Leaving?

Job #3

Employer

Address

Job Title

Supervisor's Name

Supervisor's Number

NO. supervised by you?

Date Employed (Month/Year)

Date Separated (Month/Year)

Full Time Years, Months

Part Time Years, Months

If part time, please list hours per week

Starting Salary

Ending Salary

Reason for Leaving?

Professional References
All references must include complete mailing addresses/email address and telephone numbers

Reference #1

Name

Address

Phone

Reference #2

Name

Address

Phone

Reference #3

Name

Address

Phone

Please Read Carefully Before Signing
THE ARC OF HAYWOOD COUNTY, INC. IS AN EQUAL OPPORTUNITY EMPLOYER. WE VALUE A DIVERSE, EQUITABLE AND INCLUSIVE WORKFORCE AND ENCOURAGE APPLICATIONS FROM ALL QUALIFIED INDIVIDUALS WITHOUT REGARD TO RACE, COLOR, AGE, SEX, GENDER IDENTITY OR EXPRESSION, SEXUAL ORIENTATION, RELIGION, MARITAL STATUS, CITIZENSHIP, DISABILITY OR VETERAN STATUS.

IF YOU ARE HIRED FOR ANY ROLE, PLEASE BE ADVISED THAT WE WILL REQUIRE YOU TO VERIFY THAT YOU HAVE RECEIVED YOUR COVID-19 VACCINATION SERIES (AND BOOSTER IF IT HAS BEEN 6-MONTHS SINCE COMPLETING YOUR LAST SERIES) WITHIN 60-DAYS OF HIRE UNLESS APPROVED FOR A MEDICAL OR RELIGIOUS EXEMPTION BY TAOHC IN WRITING OR ANY OTHER EXEMPTIONS AVAILABLE UNDER APPLICABLE LAW. OUR ORGANIZATION AND/OR STATE REGULATION ALSO REQUIRES HEP B VACCINATION, ANNUAL INFLUENZA, AND TB TESTING.

I UNDERSTAND THAT NEITHER THE COMPLETION OF THIS APPLICATION NOR ANY OTHER PART OF MY CONSIDERATION FOR EMPLOYMENT ESTABLISHES ANY OBLIGATION FOR THE ARC OF HAYWOOD COUNTY, INC. TO HIRE ME. IF I AM HIRED, I UNDERSTAND THAT EITHER THE ARC OF HAYWOOD COUNTY, INC. OR I CAN TERMINATE MY EMPLOYMENT AT ANY TIME AND FOR ANY REASON, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE. I UNDERSTAND THAT NO REPRESENTATIVE OF THE ARC OF HAYWOOD COUNTY, INC. HAS THE AUTHORITY TO MAKE ANY ASSURANCE TO THE CONTRARY.

I CERTIFY THAT I HAVE GIVEN TRUE, ACCURATE AND COMPLETE INFORMATION ON THIS FORM TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT FALSE INFORMATION OR DOCUMENTATION OR A FAILURE TO DISCLOSE RELEVANT INFORMATION MAY BE GROUNDS FOR REJECTION OF MY APPLICATION, DISCIPLINARY ACTION OR DISMISSAL IF I AM EMPLOYED AND/OR CRIMINAL ACTION. I FURTHER UNDERSTAND THAT DISMISSAL UPON EMPLOYMENT SHALL BE MANDATORY IF FRAUDULENT DISCLOSURES ARE GIVEN TO MEET POSITION QUALIFICATIONS. (Authority G.S. 126-30, G.S. 14-122.1).

Signature of Applicant

Date

Unsigned Applications Will Not Be Processed
Applications will be kept on file for 1 year. If you wish to apply for a different position within that time, you must fill out another application.

828-452-1980

Application

THE ARC OF HAYWOOD COUNTY, INC., APPLICATION FOR EMPLOYMENT INSTRUCTION SHEET

PERSONAL

EDUCATION

WORK EXPERIENCE

PROFESSIONAL REFERENCES

AUTHORIZATION

Training to be completed before Direct Care Services can be provided:

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