Employment Application - Quad Cities Autism Center, Inc

APPLICANT INFORMATION

First Name:

Last Name:

Birthdate:

Street Address:

Apartment/Unit #:

City:

State:

Zip Code:

Phone:

Email:

Date Available:

SSN:

Desired Salary:

Are you a citizen of the United States?

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for the Quad Cities Autism Center?

Yes No

If so, when?

Please attach a current resume and any other applicable documents via the link below:

EDUCATION

High School:

Address:

From:

To:

Did you graduate?

Yes No

Degree:

College:

Address:

From:

To:

Did you graduate?

Yes No

Degree:

Other:

Address:

From:

To:

Did you graduate?

Yes No

Degree:

REFERENCES

Please list three professional or personal references.

Full Name:

Relationship:

Company:

Address:

Phone:

Full Name:

Relationship:

Company:

Address:

Phone:

Full Name:

Relationship:

Company:

Address:

Phone:

PREVIOUS EMPLOYMENT

Company:

Address:

Phone:

Job Title:

Supervisor:

May we contact your previous supervisor for a reference?

Yes No

Responsibilities:

From:

To:

Starting Salary:

Ending Salary:

Reason for leaving:

Company:

Address:

Phone:

Job Title:

Supervisor:

May we contact your previous supervisor for a reference?

Yes No

Responsibilities:

From:

To:

Starting Salary:

Ending Salary:

Reason for leaving:

Company:

Address:

Phone:

Job Title:

Supervisor:

May we contact your previous supervisor for a reference?

Yes No

Responsibilities:

From:

To:

Starting Salary:

Ending Salary:

Reason for leaving:

AVAILABILITY

Full Time or Part Time

Full Time (37+ hours) Part Time (15+ hours)

If applying for a part-time position, please indicate availability below.

Monday

Tuesday

Wednesday

Thursday

Friday

Please list any additional information regarding availability (e.g., upcoming availability, additional hours, summer hours, etc.):

ADDITIONAL INFORMATION

Do you have knowledge/skill in using sign language?

Yes No

If yes, please explain:

Please describe any additional experience you have working with children:

Please explain why you want to work with children with Autism:

Due to the physical nature of the work we do at the Quad Cities Autism Center, Inc., candidate interviews are comprised of both a verbal and a hands-on component. Both portions are required for the interview process to be completed. Activities that you may be asked to perform include but are not limited to:

* Lift children weighing up to 50 pounds.

* Physically block a child in the event they are attempting to hurt themselves or run off.

* Engage in rigorous activities such as jumping, running, and pushing/pulling children in swings and/or wagons.

* Moving between activities quickly which often requires getting up and down from the floor repetitively.

* Climbing up and down multiple flights of stairs.

* Run and sustain behavioral procedures that may require physically blocking a child for an unspecified amount of time.

* Quickly react to actions a child may engage in that could jeopardize their safety.

Please describe any reason why you may not be able to fully perform these duties and/or complete the interview process:

CRIMINAL HISTORY INFORMATION

Have you ever been convicted of a crime other than minor traffic offense?

Yes No

If yes, please provide details (dates and location for all convictions):

Have you ever been convicted of or pleaded guilty or no contest to a misdemeanor classified as public indecency, theft, a sex offense, or an offense against a person or a family (including your own)?

Yes No

If yes, please provide details (dates and location for all convictions):

Have you ever been involved in an investigation by the Department of Family and Protective Services?

Yes No

If yes, please provide details:

Have you ever had a report of child abuse or child neglect filed against you?

Yes No

If yes, please provide details:

APPLICANT'S ACKNOWLEDGEMENT & AUTHORIZATION

I understand that his application shall be considered active for no longer than six months. After that time, I will be required to resubmit a completed application. The application will be given every consideration, but its receipt does not imply that the I will be employed. I understand that neither this document nor any offer of employment from this employer constitutes an employment contract unless the employer and employee execute a specific document in writing.

I understand that The Quad Cities Autism Center, Inc. will check the references provided in this application, including my former employers, supervisors and schools. I authorize these individuals, companies and institutions to furnish The Quad Cities Autism Center, Inc. with any information they have about me, and I release and hold them and The Quad Cities Autism Center, Inc. harmless from any liability or damage whatsoever with respect to the release or use of this information.

Dependent upon state requirements, I understand I will be required to submit other background related information so that various background checks can be conducted, including, but not limited to: criminal history, finger-print clearance, proof of licensure, etc. I understand that if I receive an offer of employment, I will be required to submit to a pre-employment drug test. Additionally, I may be required to submit to a post-accident, reasonable cause or random drug test, as a condition of employment in accordance with applicable state and federal laws. I authorize The Quad Cities Autism Center, Inc. to have access to this information.

I understand that I will also be asked to produce documents proving my identity and right to work in the United States. I attest that all information disclosed on this application is true and accurate without omissions of any kind. I understand that any misrepresentation, deception, or false statement made in this Employment Application may result in my not being considered for employment, and if not discovered by the Agency until after my becoming employed, is grounds for, and may result in, my immediate termination.

If I am hired by The Quad Cities Autism Center, Inc., I agree to comply with all company policies, procedures, and management directives. I acknowledge and understand that my employment with The Quad Cities Autism Center, Inc. is “at-will” and can be terminated by me or the agency at any time and that no one has the authority to make exceptions to this “at-will” rule except in a written agreement signed by the director of the center.

By submitting this application you acknowledge and agree to all of the above statements and conditions.

By selecting this, you agree to our Privacy Policy and Terms of Use.

Quad Cities Autism Center

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