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
Email
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?
Have you ever applied for employment with our agency?
Yes
No
What month/year did you last apply for employment with our agency?
Have you ever been employed by our agency?
Have you ever been employed by our agency?
Yes
No
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?
Are you legally eligible for employment in the United States?
Yes
No
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?
Have you ever been convicted of a FELONY, plead no contest or plead guilty to a lesser charge?
Yes
No
If you have had any convictions please list them here
Relationships
Are you a relative of an Arc Client?
Are you a relative of an Arc Client?
Yes
No
If you are a relative of an Arc Client, please indicate who
Are you the legal guardian of an Arc Client?
Are you the legal guardian of an Arc Client?
Yes
No
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
Email
Phone
Reference #2
Name
Address
Email
Phone
Reference #3
Name
Address
Email
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.
Submit Application
