National Disability Institute
1667 K Street NW, Suite 640
Washington, DC 20006
NDIis anequalopportunityemployer. We recruit, hire, and promoteemployeeswithoutregardtorace,color, religion, sex, age, sexualorientation,nationalorigin,citizenship,ordisability. Individuals withdisabilities whoneedassistancecompletingthis application can contacttheHumanResources department toarrangesuitable accommodations.
EMPLOYMENTAPPLICATION
(First)(Middle)(Last)Name / Date / SSN#
(Street)(City)(State)(Zip)
Address / PhoneNumber
Howdidyouhearaboutthisposition? Idealist.org / Birthdate
EmailAddress / Full-Time
Part-Time / SalaryDesired
PositionDesired: / DateAvailabletoWork
Other name(s) under which employmentmaybe verified Please indicate sourceof referral toNDI
If an offer of employmentismade, can you verifyyour eligibilityto workin the United States? Yes No
Are you capable of satisfactorilyperforming the essentialfunctionsof the position for which you are applying? Yes No
If position requiredtraveling, would you have anyrestrictions? Yes No
Do you have a validdriver’slicense? Yes No Hasyour driver’slicense ever been suspendedor revoked? Yes No
Have you signed, or are you otherwise boundby, anynon-compete, confidentiality, non-disclosure or other agreement(s) thatcould restrict your abilityto perform the dutiesof the position you are applying for? Yes No If yes, please explain and provide a copyof the agreement(s).
EDUCATION:
SCHOOL / CITY ANDSTATE / MAJORAREAOFSTUDY / YEARSCOMPLETED(CIRCLE) / DIDYOU
GRADUATE? Year? / DEGREERECEIVED
IFNODEGREE,GIVETOTALUNITSCOMPLETED
1234 / Yes No
Year:
1234 / Yes No
Year:
1234 / Yes No
Year:
Scholastic Honors and Awards:
Certifications:
Other Courses Taken:(Trade,Technical,Correspondence and Military) Name & Location ofSchool
CriminalHistory:Have you ever pleaded “guilty” or “no contest” to, or been convicted of, amisdemeanor or felony; or haveyou beenarrestedfor anymatter for which you are out on bailor on your own recognizance pending trial? Yes No
If yes, please explain below.(Answering“yes”tothesequestionsdoesnotconstituteanautomaticbartoemployment.Donotincludeminortrafficviolations.)
Would you be willing to be subject to an official background check? Yes No
Employment: May we contact your present and/or former employer(s)? YES NOCONDITIONS ______
Have you ever been discharged or asked to resign by any previous employer? (Do not include layoffs)
YESNO If Yes, please explain
EMPLOYMENTRECORD:
Listall jobsand otheractivities (includingmilitaryservice)foratleastthe past10years,covering full disposition ofyourtime whetheryou were employed ornot(showlastemploymentfirst). Thisportion mustbe completedeven ifsupplemented bya resume. Please explain fullyany gapsin employmenthistory. Ifnecessary,please attach a separate sheetforadditional employmenthistory.
EMPLOYMENTHISTORY(Give fullname and complete streetaddress). / * / DUTIES / DATES
EMPLOYED / TOTAL
YRS/MO / REASONFORLEAVING
SALARY/
WAGE / From
MO/YR / To
MO/YR
Organization / Start
:
PositionHeld
Street / Last:
CityState
Supervisor/ Phone#
Organization / Start:
PositionHeld
Street / Last:
CityState
Supervisor/Phone#
Organization / Start:
PositionHeld
Street / Last:
CityState
Supervisor/Phone#
Organization / Start:
PositionHeld
Street / Last:
CityState
Supervisor/Phone#
References:
Please list three referenceswho are not related to you and are familiar with your employment experience(at least onedirect supervisor).
Name: __
Title:
Company:______
Address:
City/State/Zip:
Name:
Title:
Company:
Address:
City/State/Zip:
Name:
Title:
Company:
Address:
City/State/Zip:
Daytime Telephone:
EmailAddress:
Daytime Telephone:
EmailAddress:
Daytime Telephone:
EmailAddress:
Prior SupervisorProfessionalContact
Co-workerOther
Prior SupervisorProfessionalContact
Co-workerOther
Prior SupervisorProfessionalContact
Co-workerOther
I herebycertifythatmyanswerstotheforegoingquestionsandstatementsaretrueandcorrecttothebestofmyknowledgeandIherebyauthorizeNational Disability Institute(hereaftercalled“NDI”)toverifyanyoftheinformationconcerningmyemployment,education,anddisciplinaryhistorywiththeappropriateindividuals,companies,institutions,or agencies;andI authorizethemtoreleasesuchinformationwithoutanyobligationtogivemenoticeofsuchdisclosure.I herebyreleaseNDIandallindividualsfromanyliabilityforanydamage whatsoeverforissuingthisinformation.
I understandthatanymisrepresentationor omissionofmaterialfactinthisapplicationwillconstitutesufficientgroundsforimmediatedismissal.I furtherunderstandNDIisan “at will”employer.Ifhired,employmentisfornodefiniteperiod,is based on available funding and satisfactory work performance, and maybeterminatedatanytimeforanyreason,withorwithoutcause and with or without notice,bymeor NDI.Noimplied,oral,orwritten agreementscontrarytotheexpresslanguageof theagreementarevalidandnoagentof NDIhastheauthoritytooverridethepresumptionofat-willemployment.
I understandthatNDImaintainsa drug-freeworkplace.Employmentisconditionalupontheresultsofreferences,verificationofeligibilityforemploymentintheUnitedStates, andsigningconsentwithNDI’spoliciesandprocedures.I understandandagreethatthetermsandconditionsofemploymentmaybealteredbyNDIatanytimewithor withoutcauseornotice.
Signature of Applicant:
Thisapplication isvalid for90days.If you wish to be considered foremploymentafter thistime, you must reapply.