The Arc of the Mid-South

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THE ARC OF THE MID-SOUTH EMPLOYMENT APPLICATION

Note: The Arc of the Mid-South will not consider incomplete or unsolicited applications

Position you are seeking:
Family Support Service	Career Development & Job Placement	Administrative	Volunteer

How did you learn about this position?
Advertisement(Specify source)	Friend	Employment Dept	Walk-In	Website	Other

SSN
Last Name
First Name
Middle Name
Address
City
State
Zip
Phone
Email
Date	(MM/DD/YYYY)

	Please answer the following questions:
	Have you ever filed an application with Arc of the Mid-South before? Yes No if yes,please give date:
	Do any of your friends or relatives, other than a spouse work here? Yes No If yes, please give name, relationship and position
	Have you ever been employed with Arc of the Mid-South before? Yes No If yes, , please give date and position
	Are you at least 18 years of age? Yes No
	If you are under 18 years of age, can you provide proof of your eligibility to work? Yes No
	Are you a US citizen? Yes No
	If not a US citizen, do you have proof of your legal right to accept employment? Yes No
	Are you currently employed? Yes No
	If yes, may we contact your current employer? Yes No
	Are you currently on lay-off status and subject to recall? Yes No
	Will you travel if a job requires it? Yes No
	Will you work overtime? Yes No
	Have you ever been convicted of a crime? Yes No If yes, please give date and reason for conviction: (All positions at OMSI are subject to a Criminal Background Check.)
	Are you capable of performing any work duties, with or without reasonable accommodation? Yes No
	Date available for work:
	What is your desired salary range?

Please check your availability to work:
Regular Full-Time	Regular Part-Time at ____ hours/week
Temp/Seasonal Full-Time	Temp/Seasonal Part-Time at _____hours/week
Morining	Afternoons
Evenings	Weekends
Sundays

School	Name, City & State of School	Course of Study	# years	Diploma/Degree
High School				Yes No
Undergraduate				Yes No
Graduate School				Yes No
Other(Specify)

Please state any additional information and skills you feel may be helpful to us in considering your application:

Work Experience – Complete this section even if you are attaching a resume

Begin with your current or last job. Include any job-related military service assignments and volunteer activities. You may exclude any organizations that indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer:	Date Employed:	From:	To:
Address:	Hourly/Salary Rate	Start:	End:
Supervisor & Telephone #	May we contact		Yes No
Job Title	Reason for leaving
Work performed/Responsibilities:

Employer:	Date Employed:	From:	To:
Address:	Hourly/Salary Rate	Start:	End:
Supervisor & Telephone #	May we contact		Yes No
Job Title	Reason for leaving
Work performed/Responsibilities:

Employer:	Date Employed:	From:	To:
Address:	Hourly/Salary Rate	Start:	End:
Supervisor & Telephone #	May we contact		Yes No
Job Title	Reason for leaving
Work performed/Responsibilities:

Professional References – Please do not include family members.

Name	Address & Phone Number	Occupation

Applicant’s Certification – Please read this carefully before signing the application!

*Arc of the Mid-South is an equal opportunity employer and will consider applicants for all positions without regard to race, age, color, religion, marital status, nation origin, disability, veteran status or any other legally protected status.

*No applicant will be rejected as a result of any impairment, which, with reasonable accommodation, does not prevent performance of the work.

*Arc of the Mid-South will not tolerate sexual harassment or harassment on the basis of any protected class status in the workplace.

*I understand that, if selected, I will be required to provide proof of my identity and legal right to work in the United States prior to actual employment at Arc of the Mid-South.

*I certify that I have answered truthfully and have not knowingly withheld information relative to my application. I understand that any misrepresentation or material omission on the application will result in my being eliminated from further consideration. I further understand that, if accepted for employment, any misrepresentation or material omission that becomes known to Arc of the Mid-South may result in immediate termination of my employment.

*I hereby authorize all previous employers and supervisors, including all persons with and for whom I have worked, to give Arc of the Mid-South’s representative’s any and all information regarding me and my previous employment. I release Arc of the Mid-South and all previous employers and supervisors from liability for any damages that may result from furnishing information to Arc of the Mid-South.

*In consideration of my employment, I agree to adhere to all existing and future instructions, rules and policies of Arc of the Mid-South. I also understand that Arc of the Mid-South reserves the right to change wages, hours and working conditions as deemed necessary and that no representative of Arc of the Mid-South has any authority to enter into any agreement for employment for any specified period or to make any agreement contrary to the foregoing.

*I understand that all employees of Arc of the Mid-South, with respect to length of employment, are considered to be “at will.” This means that I may terminate my employment with Arc of the Mid-South at any time, without notice, without liability, for any extended period. Similarly, Arc of the Mid-South may terminate my employment with Arc of the Mid-South at any time without notice, without liability, for any extended period. There is no guaranteed length of employment for any employee. Similarly, any representation by any agent or employee of Arc of the Mid-South to the contrary is not authorized or binding upon Arc of the Mid-South unless in writing and signed by the President or Executive Director of Arc of the Mid-South.

*I, the undersigned applicant, certify and affirm that, to the best of my knowledge and belief; I have or have not (as applicable) had a case of abuse, neglect, mistreatment or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation I further release and authorize Memphis Shelby County Association of Retarded Citizens (Arc of the Mid-South) and the Tennessee Division of Mental Retardation Services to have full and complete access to any and all current or prior personnel or investigative records, from any party, person, business or agency, as pertains to any substantiated allegations of abuse, neglect or mistreatment.

I have read and reviewed the above certification statements and other information provided on the application.

Submit it online by clicking on the SUBMIT button.

If you feel any of the above information is incorrect you could start filling out the form from the beginning by pressing the RESET button.

An equal Opportunity Employer