Job Application - Autism Awareness

Applicant Information

Applicant Name:*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Telephone Number:*

Email Address:*

Date of Application:*

Employment Position

Position(s) applying for: Event Coordinator ( part time)

How did you hear about this position?*

What days are you available for work?*

What hours or shift are you available for work?*

On what date can you start working if you are hired?*

Personal Information

Do you have any friends, relatives, or acquaintances working for Autism Awareness - NEPA Yes No*

Yes

If yes, state name & relationship:

Are you 18 years of age or older?*

Yes

Are you a U.S. citizen or approved to work in the United States?*

Yes

What document can you provide as proof of citizenship or legal status?

Do you have any condition which would require job accommodations?*

Yes

If yes, please describe accommodations required below.

Have you ever been convicted of a criminal offense (felony or misdemeanor)?*

Yes

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:*

(Note: Autism Awareness - NEPA complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )

Education and Training

High School*

Name

Location (City, State)

Year Graduated

Degree Earned

College/University

Name

Location (City, State)

Year Graduated

Degree Earned

Vocational School/Specialized Training*

Name

Location (City, State)

Year Graduated

Degree Earned

Military:

Are you a member of the Armed Services?*

What branch of the military did you enlist?*

What was your military rank when discharged?*

How many years did you serve in the military?*

What military skills do you possess that would be an asset for this position?*

Previous Employment

Employer Name:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

List*

References

Contact Information

AT-WILL EMPLOYMENT

The relationship between you and the Autism Awareness - NEPA is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Autism Awareness - NEPA. No representative of Autism Awareness - NEPA has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature*

Dated:*