Job application

HILL COOPERATIVE YOUTH SERVICES, INC. NEW HAVEN RESOURCE DEVELOPMENT AGENCY 158 CARLISLE STREET, P.O. BOX 7601 NEW HAVEN, CONNECTICUT 06519 (203) 624-4108 AN EQUAL OPPPORTUNITY EMPLOYER APPLICATION FOR EMPLOYMENT 1.

Job Applying For:

2.

Last Name: 3. Address

City: Telephone #:

First:

Middle:

State: 5. Social Security #

Zip code: -

-

6. Are you at least 18 years old?

Y N 7. Have you ever been convicted of any offense other than a minor traffic violation or juvenile offenses? YES

NO

If “yes” give details and dates of convictions below: NOTE: Conviction is not necessarily disqualifying ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Are you presently on Parole or Probation?

Y N If so please list conditions and restrictions. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Personal References besides family members: Name:______________________________Address__________________________________________Phone__________ Name:______________________________Address__________________________________________Phone__________ Name:______________________________Address__________________________________________Phone__________ Hill Cooperative Youth Services, Inc. is an equal opportunity employer. The Civil Rights Act of 1964 and State and Local laws prohibit discrimination on the basis of race, color, religion, sex, or national origin. In addition, State and Local laws prohibit discrimination on the basis of disability and the Age Discrimination in Employment Act of 1967, and some State and Local laws prohibit discrimination on the basis of age with respect to individuals who are at least 40, but less than 70 years of age. It is our policy to comply fully with these Acts and information requested on this application will not be used for any purpose prohibited by law.

8. EDUCATION: A. Did you graduate from High School? B. If you have a high school equivalency certificate, give the Year and place The certificate was granted: Yes month: year: No Highest grade completed: Year: Place: C. Last high school, grade school, or trade school you attended: NAME OF SCHOOL LOCATION DATES ATTENDED COURSE D. List any colleges, graduate schools, business schools or technical schools attended: NAME OF SCHOOL LOCATION DATES COURSE OR ATTENDED MAJOR

DEGREE / DIPLOMA

9.

Any other training, special courses or subjects related to the job for which you are applying. Where was training received? List licenses (including drivers); machines you operate, other languages other than English, which you speak, read write fluently. Typing or stenography speeds; any other special skills or abilities related to the job you want. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ______________________________________________________ Do you have a valid Conn. Drivers license?

YES NO If not Connecticut, what State?

Please list your license I.D. # If your license is presently under suspension or restricted, please explain in detail. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ APPLICANT PLEASE NOTE: VALID DRIVERS LICENSE IS REQUIRED FOR MOST POSITIONS.

10. EXPERIENCE: Start with your present or last job, and work back listing all paid and unpaid, full or part-time work, military service, and summer jobs performed during the last 5 years. Use additional sheets of paper if you need more space.

Work performed more than 5 years ago may be listed if it applies to the job you want. (IF MORE SPACE IS REQUIRED, ATTACH ADDITIONAL SHEETS OR RESUME, IF AVAILABLE.) STARTING DATE: MONTH YEAR

NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER:

ENDING DATE: MONTH YEAR SALARY:

HOURS PER WEEK:

NAME OF YOUR SUPERVISOR:

REASON FOR LEAVING: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ YOUR JOB TITLE: __________________________________________________________________________________ YOUR DUTIES: STARTING DATE: NAME AND ADDRESS OF EMPLOYER: MONTH YEAR ENDING DATE: MONTH YEAR SALARY:

HOURS PER WEEK:

NAME OF YOUR SUPERVISOR:

REASON FOR LEAVING: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ YOUR JOB TITLE:___________________________________________________________________________________ YOUR DUTIES: STARTING DATE: NAME AND ADDRESS OF EMPLOYER: MONTH YEAR ENDING DATE: MONTH YEAR SALARY:

HOURS PER WEEK:

NAME OF YOUR SUPERVISOR:

REASON FOR LEAVING: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ YOUR JOB TITLE:___________________________________________________________________________________ YOUR DUTIES: CERTIFICATION: I certify that all statements made on or in connection with this application are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I authorize the Hill Cooperative Youth Services, Inc., to obtain necessary information and records regarding any criminal convictions specified in number 7 of this application. I understand that incomplete, false or inaccurate information may result in the rejection of this application or my dismissal if employed.

DATE:

SIGNATURE OF APPLICANT: OFFICE USE ONLY

DATE OF INTERVIEW: ____________________________________________ TIME APPLICANT ARRIVED: ________________AM___________________PM INTERVIEWED BY: ______________________________________________ COMMENTS: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________