Application for Employment

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If accommodation or assistance is needed in completing this application, contact Rowell
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Position applying for?

When can you start?

Far Northern Client you're applying for:

Education and/or Training

Did you graduate from high school or receive a GED Certificate?

YesNo

School Name #1

College, business, nursing, vocational, or other

Field/Major/Minor

Diploma or degree earned

#1 Did you graduate?

YesNo

School Name #2

College, business, nursing, vocational, or other

Field/Major/Minor

Diploma or degree earned

#1 Did you graduate?

YesNo

Diploma or degree earned

Computer skills, related volunteer experience, and other education/training skills:

Licence or Certification

	Lic. or Cert.	State	Profession	Lic/Cert. #	Exp Date

Employment History

May we contact your current employer?

YesNoNot Applicable

Employer/Job Information

Employer

Type of Business

Telephone Number

Supervisor's Name

Your Job Title

Average Hours Worked Per Week

Duties:

Dates Employed-From/To (indicate months & Years)

Reason for leaving

Employer/Job Information

Employer

Type of Business

Telephone Number

Supervisor's Name

Your Job Title

Average Hours Worked Per Week

Duties:

Dates Employed-From/To (indicate months & Years)

Reason for leaving

Employer/Job Information

Employer

Type of Business

Telephone Number

Supervisor's Name

Your Job Title

Average Hours Worked Per Week

Duties:

Dates Employed-From/To (indicate months & Years)

Reason for leaving

Special Qualifications

Describe trainings, life or work experiences, studies, special skills relevant to working with families who have children with special needs:

Have you worked with parents of children with special needs? If yes, please explain:

Do you have reliable transportation?

YesNo

References (Please list 3 persons who are not relatives)

Reference #1

Name

Phone Number

Business

Years Acquainted

Reference #2

Name

Phone Number

Business

Years Acquainted

Reference #3

Name

Phone Number

Business

Years Acquainted

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I certify that all information contained in this application and any attachments is true and complete to the best of my knowledge. I understand that any willful misrepresentation, false statement, or omission by me in the application or interview process will be cause for rejection of my application or termination of my employment. I authorize investigation of all statements make on this application and any attachments, and I release all persons, companies, and organizations from liability for providing or receiving such information. I further understand that this employment application and other employment related documents are not contracts of employment; and that any oral or written statements to the contrary are hereby expressly disavowed.

Applicant's Name

Date Completed

ALL STAFF OF ROWELL ARE REQUIRED TO SIGN A CONFIDENTIALITY AGREEMENT. BY SIGNING A CONFIDENTIALITY AGREEMENT, YOU AGREE TO KEEP CONFIDENTIAL ALL INFORMATION YOU LEARN ABOUT CLIENTS DURING YOUR WORK FOR THIS COMPANY.

Equal Opportunity Employer
Rowell Family Empowerment of Northern California does not discriminate on basis of race, color, national origin, sex, religion , age, or disability in employment or the provision of services.

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