Delmarva Community Services, Inc.
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Title VI information
united way of the lower eastern shore
Chesapeake Grove
Employment Application Online Form
Name
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First
Last
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Personal Information
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Indicates required field
Email Address
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We don't share this information!
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Social Security Number
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Do not use hyphens
Are you at least 18 years of age?
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Yes
No
Are you legally eligible for employment in the U.S.A?
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Yes
No
Position Applying for:
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Driver
Residential Care
Habilitation Day
Medical Adult Care
Administration
Other
If your application is considered favourably, on what date will you be available for work?
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Were you previously employed by us?
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Yes
No
If yes, when or what year?
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Are there any other job - related experiences, skills or qualifications?
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Employment History
In this section, list present and past employment, beginning with most recent. Please complete information for up to 4 employers.
Upload Resume
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Max file size: 20MB
If you have a resume prepared, please upload here
I hearby give permission to contact the following employers concerning my prior work experience:
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Employer 1
Employer 2
Employer 3
Employer 4
Employer 1
Employer 1 - Name
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Employer 1 - Phone
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Employer 1 - From Month/Year to Month/Year:
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(i.e., Jan. 1, 2002 to Feb. 12, 2012)
Employer 1 - Weekly starting salary
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Employer 1 - Weekly ending salary
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Employer 1 - Reason for leaving:
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Employer 1 - Name of Supervisor
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Employer 1 - Describe the work you performed:
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Employer 2
Employer 2 - Name
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Employer 2 - Phone
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Employer 2 - From Month/Year to Month/Year
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Employer 2 - Weekly Starting Salary
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Employer 2 - Weekly ending salary
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Employer 2 - Reason for leaving
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Employer 2 - Name of Supervisor
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Employer 2 - Describe the work you performed:
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Motor Vehicle
Excluding minor traffic offenses, in any criminal (misdemeanor or felony) investigation or proceeding, have you ever plead guilty o r"not contest" to a crime, or been convicted or received a verdict of anything other than "not guilty" or sentenced to probation before judgement, or adjudged not criminally responsible (including during military service)? Do no include offenses that have been annulled, expunged, shielded or sealed by a court.
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Traffic Offenses
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YES
NO
Valid Driver License
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YES
NO
Valid CDL
APPLYING FOR BUS DRIVER POSITION (MINIMUM AGE 21))
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YES
NO
Have you been convicted of, or plead guilty to, any traffic related offenses within the past 5 years?
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YES
NO
Do you have points on your driver's license?
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YES
NO
How many?
Have you ever had your driver's license suspended or revoked or had your driving privileges modified by a court of law?
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YES
NO
In the past three years have you had
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more than two at-fault accidents?
more than three minor moving violations?
more than four non-moving violations such as failure to appear, license not in possession, or no proof of insurance/registration?n
four or more in combination of the above?
In the past four years, have you had zero major moving violations? Major violations include, but are not limited to, driving while license is suspended, revoked or invalid, exhibition of speed - speed contest, reckless driving, driving under the influence, vehicular manslaughter, leaving the scene of an accident (hit and run), and speeding in excess of 100 mph?
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YES
NO
Option 3
Record of Education
Name and Address of Elementary School:
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Did you graduate?
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Yes
No
Name and Address of High School?
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Course of Study
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Indicate last year completed:
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9
10
11
12
Did you Graduate?
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No
Yes
Diploma or Degree:
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Name and Address of College:
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Course of Study
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Did you Graduate?
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Yes
No
Not Yet
Indicate Graduation year or anticipated graduation year:
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Diploma or Degree:
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Name and Address of Other Education:
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Course of Study
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Did you Graduate?
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Yes
No
Not Yet
Indicate graduation year or anticipated graduation year:
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Diploma or Degree:
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Personal References
Name and Occupation:
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Phone Number
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Address
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City
State
Zip Code
Country
Name and Occupation:
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Phone Number
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Address
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Line 2
City
State
Zip Code
Country
Name and Occupation
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Phone Number
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Address
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City
State
Zip Code
Country
Permission and Agreement
May we telephone you at home to follow up on this application?
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Yes
No
When is the best time to contact you?
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Morning
Afternoon
May we telephone you at work to follow up on this application?
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Yes
No
When is the best time to contact you?
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Morning
Afternoon
I agree to the terms and conditions listed at the right of this page:
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Yes
By submitting details in above form you're agree to following terms:
1.
Under Maryland law, an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100.
2.
The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I further understand that this application is not and is not intended to be a contract of employment, not does this application obligate the employer in any way if the employer decides to employ me. I understand and agree that my employment is at will and can be terminated by either party with or without notice, at any time, for any reason or no reason. No one other than an officer of the Company has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and then only in a writing signed by an officer.
3
. I authorize the investigation of all statements contained in this application and release all liability any persons or employers supplying such information, and I also release the company from all liability that might result from making the investigation.
4
. I certify that all facts and information set forth in this application are true and complete to the best of my knowledge. I understand that my falsification, misrepresentation or omission, of facts on this application (or any required documents will be cause for denial of employment or immediate discipline, up to and including termination of employment, regardless of when or how it was discovered.
5
. I agree, if I am offered and accept a position, to conform to all existing and future rules and regulations and I understand that the Company reserves the right to change policies, titles, job descriptions, wages, hours, and working conditions, as deemed necessary.
6
. I understand that any employment offer is contingent upon my providing, within (3) working days of employment, valid proof of identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986.
7
. I have read and reviewed the information provided in this application and the above statements. By signing this application for employment, I certify that I understand all parts of it and that I have answered all questions completely and fully.
I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME FOR ANY REASON OR NO REASON AND THAT ONLY A WRITTEN AGREEMENT BETWEEN THE PRESIDENT/CEO OF THE COMPANY AND ME, SIGNED BY BOTH OF US, CAN ALTER THE AT-WILL EMPLOYMENT RELATIONSHIP.
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