Application for Employment
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
 
Personal Information
 Please provide the necessary personal information required below.
 
* = required field
*Application Date: *Position Applying For:
*First Name: *Middle Name:
*Last Name: *Address:
*City: *State:
*Zip: *Phone number:
*Email: *County:
       
Additional Information:
How long have you lived at your current address? Years Months
Have you ever filed an application with us before?
Yes No
If yes, please provide date:
Have you ever been employed with us before?
Yes No
If yes, please provide date:
Do you have any relatives working at Potomac Center?
Yes No
If yes, please provide name:
If yes, provide relationship:
May we contact your present employer?
Yes No
On what date would you be available for work?
Are you prevented from lawfully becoming employed in this country because of Visa or immigration? (Proof of citizenship or immigration status will be required upon employment.)
Yes No
Are you available to work:
  Full Time Part Time Temporary
 
  1 2 3
Shift
Are you currently on "lay-off" status and subject to recall?
Yes No
Can you travel if a job requires it?
Yes No
Have you been convicted of a felony within the last ten years? (Conviction will not necessarily disqualify an applicant)
Yes No
If yes, please provide date:
   
 
Educational Information
 Please provide the necessary educational information required below.
 
High School Undergraduate
College/University		 Graduate/Professional
School Name/Location
Diploma Degree
Describe course of study
Describe any specialized training, apprenticeship, skills and extracurricular activities:
Describe any honors you have recieved:
State any additional information that you feel may be helpful to us in considering your application:
List professional, trade, or business, activities and offices held:
   
 
Employment History
 Begin with your current or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.		  
 
May we contact your current employer?
Yes No
May we contact your previous employers?
Yes No
First Employer:
Employer/Company Name: Address:
Telephone/Fax:
Phone: Fax:
Dates Employed:
From: To:
Job Title: Supervisor:
Work Performed:
Reason for leaving:
Second Employer:
Employer/Company Name: Address:
Telephone/Fax:
Phone: Fax:
Dates Employed:
From: To:
Job Title: Supervisor:
Work Performed:
Reason for leaving:
Third Employer:
Employer/Company Name: Address:
Telephone/Fax:
Phone: Fax:
Dates Employed:
From: To:
Job Title: Supervisor:
Work Performed:
Reason for leaving:
Fourth Employer:
Employer/Company Name: Address:
Telephone/Fax:
Phone: Fax:
Dates Employed:
From: To:
Job Title: Supervisor:
Work Performed:
Reason for leaving:
   
References
 Please provide name, address and telephone number of four references who are not related to you and are not previous employers.
   
Reference 1      
Name:    
Address:    
Telephone Number:    
       
Reference 2      
Name    
Address:    
Telephone Number:    
       
Reference 3      
Name:    
Address:    
Telephone Number:    
       
Reference 4      
Name:    
Address:    
Telphone Number:    
       
Policy Rights and Disclaimer
 Please review the following policy rights and the application disclaimer. If you agree to the terms please type your name and date in the corresponding fields, this will be your digital signature that you agree to the terms of the application disclaimer.
 

SUBSTANCE AND SUBSTANCE ABUSE POLICY
Potomac Center, Inc. has an Illegal Substance Policy (Effective Date: May 1, 1994).
Employees have the right to review this policy.

Potomac Center, Inc. has an Infectious Disease Policy (Effective Date: February 1, 1993).
Employees have the right to review this policy.

APPLICANTS STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize the Potomac Center to investigate all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed six (6) months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether applications are being accepted at this time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employees may resign at any time after providing appropriate notice, and the Employer may discharge Employee at any time with or without cause.

In the event of employment, I understand that knowingly false or knowingly misleading information given in my application or interview(s) shall result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature: Date:

 
Request for References Release
 Please review the following release and sign and date.
 

I hereby authorize the release of my personnel records from all previous employers to Potomac Center, Inc. whether they be complimentary or detrimental to my application for employment with them, upon submission of this form containing my digital signature provided below.

Signature: Date: