POINT O’WOODS ASSOCIATION, INC
Application for Employment
We consider applicants for all positions without regard to race, color, religious creed, sex, age, national origin, age, ancestry, marital status, sexual orientation, mental retardation and past/present history of mental disorder, learning disability and physical disability.
(Please answer all questions and print legibly)
If completing electronically, enter information requested in the gray box.
Position(s) applying for:Date (mm/dd/yy):
/ Name (Last/First/Middle):
Street Address: / Telephone Number:
City/State/Zip: / Cell Phone Number:
Are you available to work:
Full Time Part-Time / On what date would you be available to work (mm/dd/yy):
Email address:
/ Are you over 16 years of age:
Yes No
EMPLOYMENT HISTORY
(Start with most recent)
1. / Employer Name, Address & Phone:
Phone: / Job Title:
From: To:
Reason for Leaving:
2. / Employer Name, Address & Phone:
Phone: / Job Title:
From: To:
Reason for Leaving:
3. / Employer Name, Address & Phone:
Phone: / Job Title:
From: To:
Reason for Leaving:
4. / Employer Name, Address & Phone:
Phone: / Job Title:
From: To:
Reason for Leaving:
For additional information, continued on a separate sheet of paper.
Schools/Colleges / Dates / Major & Degree
From:
To:
From:
To:
From:
To:
Describe any specialized training, apprenticeships, skills and extra-curricular activities:
Describe any honors you received:
List professional, trade, business or civic activities and/or offices held:
List any additional information you feel may be helpful to us in considering your application:
HEALTH & SAFETY CERTIFICATION
Are you certified in CPR? Yes No / Expires(mm/dd/yy):
Are you certified in First Aid? Yes No / Expires(mm/dd/yy):
Can you swim? Yes No
MILITARY SERVICE
Branch of Military Service: / Rank at Discharge:
/ Discharge Designation:
Period of Active Duty -> / Induction Date: / Discharge Date:
REFERENCES
Provide the following information on 2 personal references not related to you and 1 previous employers (if applicable)
Name / Address / Phone
OTHER INFORMATION
State any additional information you feel may be helpful to us in considering your application:
AUTHORIZATION TO WORK IN UNITED STATES
Are you either a U.S. citizen or an alien authorized to work in the United States? / Yes No
If your authorization to work in the United States is subject to expiration, when will it expire? (mm/dd/yy) / Date:
Are you prevented from lawfully becoming employed in this country because of VISA or immigration status? / Yes No
If employment is offered, can you produce documentation required by law to establish work authorization and identity? / Yes No
Have you ever been convicted of a felony or any other criminal offense either within or outside of the State of Connecticut? Yes No
Describe briefly:
Are any criminal charges currently pending against you either within or outside of the State of Connecticut? Yes No
If yes, please identify the jurisdiction in which such charges are pending, the nature of the charges and an explanation on a separate sheet of paper and attach it to this application.
Are you currently enrolled in a program of deferred adjudication (e.g., accelerated rehabilitation, pre-trial drug or alcohol education pursuant to Connecticut General Statutes §54-56g)? Yes No
If yes, please identify the jurisdiction in which such program is pending and an explanation of the nature of such program on a separate sheet of paper and attach it to this application.
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
I understand that should I be granted an interview, no representations that may be made at the interview are to be construed as creating any obligation, promise or contract on behalf of Point O’Woods Association.
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 Employee may resign at any time and the Employer may discharge an Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or conduct unless such change is specifically acknowledged in writing by an authorized representative of the Point O’Woods Association, Inc.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Point O’Woods Association.
______
Signature of ApplicantDate
Please return this application to:
Point O’Woods Association, Recreation Commissioner
P O BOX 152, South Lyme, CT 06376
AND
FAIR CREDIT REPORTING ACT DISCLOSURE
As part of the interview process, The Point O’Woods Association, Inc. (“The Association”) may conduct a background check. If you are hired, The Association may also conduct a background check in deciding whether to continue your employment and when making employment-related decisions directly affecting you. As part of the background check, The Association may obtain a “consumer report” from a “consumer reporting agency”. These terms are defined by the Fair Credit Reporting Act (“FCRA”), which applies to you. A consumer report includes information regarding such issues as your credit standing, criminal record, motor vehicle record, character and reputation. If The Association obtains a “consumer report” about you, and considers any information in the “consumer report” when making an employment-related decision that directly and adversely affects you, you will be provided with a copy of the report before the decision is finalized. You may also contact the Federal Trade Commission in Washington, D.C. about your rights under FCRA as a consumer with regard to “consumer reports” and the “consumer reporting agencies” that prepare these reports. Your signature below authorizes The Association to obtain consumer reports regarding you from consumer reporting agencies in connection with your application and during the course of your employment.
To perform the background check, please provide the following information:
Social Security Number:--
Driver’s License Number: State:
Print Name:
Print Former Name (if any):
Signature: ______Date:
AUTHORIZATION TO COLLECT BACKGROUND INFORMATIONI have applied for employment at the Point O’Woods Association, Inc., (“The Association”). I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I authorize representatives of The Association to obtain pertinent information from my previous employers, references, and other persons with knowledge of my work history and background, financial history, education, regulatory or police records, driving records, licensing status or professional designation, and character or reputation, and to consider the information provided by the background check when making decisions regarding my employment at The Association.
I authorize all previous employers, references or other persons having knowledge of my record or myself to release such information to The Association and hereby release all persons from liability for any damage that may result from furnishing such information to The Association.
A photocopy of this authorization may be accepted in lieu of the original.
Signature: ______Date:
Print Name:
Print Former Name (if any):
CRIMINAL BACKGROUNDNOTE
THIS PORTION OF THE APPLICATION WILL ONLY BE REVIEWED BY MEMBERS OF THE HUMAN RESOURCES DEPARTMENT (OR THE PERSON(S) IN CHARGE OF EMPLOYMENT) AND ANYONE INVOLVED IN INTERVIEWING THE APPLICANT
Have you ever been convicted of, or pleaded guilty or nolo contendere (no contest) to a violation of any state, federal, county, or municipal law? (Do not include minor traffic violations)
YesNo
If yes, please give information regarding the nature of the charge, the date and location of conviction and the final disposition of the case:
Applicants are not required to disclose the existence of an arrest, criminal charge or conviction for which the records have been “erased”. The types of records subject to erasure under Connecticut law are as follows: (a) a finding of delinquency or that a child was a member of a family with service needs; (b) a sentence as a youthful offender; (c) a criminal charge that was dismissed or “nolled”; (d) a criminal charge for which the person was found not guilty; and (e) a conviction for which a person received an absolute pardon.
Any applicant whose criminal records were erased will be considered to have never been arrested and may so swear under oath.
I understand that the information provided above will not necessarily result in rejection of my application, but that the nature of the information will be considered as it relates to the performance of the job duties in question and in light of the requirements of the state and federal law.
______
Signature of ApplicantDate
POW Employment ApplicationPage 1 of 7