a Division of Ark Industries & Rehabilitaion Center

Selected Program accredited by CARF...The Rehabilitation Commission

1150 N. 3rd - Laramie, WY 82072

Phone: (307)742-6641 Fax: (307)742-9203

Web: www.arkregionalservices.org

Application for Employment

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or vetern status, or the presence of a no-job-related disability.

Date: Position Applied for: Date available for work:

Last Name: First Name: MI: Social Security Number:

Address: City: State: Zip Code:

Phone Number: Alternate Phone Number: Email Address:

Relatives working for Ark Regional Services (Name, relation, and position in which they work):

Have you ever been employed by Ark Regional Services? Yes No

If yes, position: Dates of employment:

Supervisor's name and title:

Reason for leaving:

General Positions:

Day Hab positions: Monday - Friday 8am - 5 pm

Residential positions: early mornings, evenings, weekends, and awake overnight

Days and times you are available to work:

Are you available to work?

Full time? Yes No

Part time? Yes No

COMPLETE THIS SECTION ONLY IF THE MINIMUM QUALIFICATIONS OF THE JOB THAT YOU ARE APPLYING FOR REQUIRE THAT YOU HAVE A VALID DRIVER'S LICENSE

Are you at least 20 years of age? Yes No

Have you had a major violation such as a DUI, Reckless Driving, Leaving the Scene, or suspended license within the last 5 years? Yes No

Have you had more than two minor traffic violations such as speeding within the last three years? Yes No

ALL EMPLOYEES AT ARK REGIONAL SERVICES HAVE CONTACT WITH PEOPLE WITH INTELLECTUAL DISABILITIES THEREFORE ALL APPLICANTS MUST COMPLETE THIS SECTION.

Have you ever been convicted of an offense of abuse, neglect, and explotation of children or disabled adults or crimes against person(s) or property including but not limited to simple assault and battery or offenses against the family such as violation of order of protection? Yes No

If yes: Date of conviction: Describe the circumstances:

Have you been convicted of a felony within the last 7 years? Yes No

If yes: Date of conviction: Describe the circumstances:

The existence of a record of convictions for criminal offenses is not considered an automatic bar to employment.

Do you have a High School Diploma or GED Certificate? Yes No

Last High School Attended:

College or Vocational School	Dates: To - From	Semester Hours	Quarter Hours	Major	Minor	Degree Earned

List any other job related special qualifications and skills. Include special training, skills with machines including computers, typing, or shorthand speed, language skills, memberships in professional associations, honors, awards, publications, licenses, or registrations. For licenses and registratons please note expiration dates and license/registration number.

Work history: List jobs in reverse order starting with your present or last job. List your entire work history including volunteer, part time, temporary, self-employment, and military jobs. List each promotion as a seperate job. This section must be accurate and complete. If more space is needed, attach additional sheets in the same format including your name, social security number, and job title. Ark Regional Services will do a complete verification of your work and personal history including public records.

Employer/Company: Phone:

Address: City: State: Zip Code:

From: Mo/Yr To: Mo/Yr Hours worked each week:

Supervisor: Phone Number: May we contact? Yes No

Did you supervise? Yes No

If yes, number of employees supervised:

Reason for leaving:

General Duties:

Personal References:

List name, address including street, city, state, and zip code, and telephone number of three references who are not related and are not previous employers. Providing this information means that you give this organization permission to contact the references listed.

Name	Address	City	State	Zip Code	Phone Number

APPLICANT'S ACKNOWLEDGEMENTS
(This application shall be considered active for the job vacancy listed and for no more than 60 days. After that time, the applicant will be required to resubmit a completed application. THE APPLICANT UNDERSTANDS THAT NEITHER THIS DOCUMENT NOR ANY OFFER OF EMPLIOYMENT FROM THIS EMPLOYER CONSTITUTES AN EMPLOYMENT CONTRACT .)
I certify that all information contained on this application is true and that I have provided complete responses to all requests for information on the application. I give Ark Regional Services and its authorized agents permission to verify and investigate any employment, license, criminal background, and personal reference information given in connection with this application. In the event that I am employed, I understand that any false or misleading information I knowingly provided on my application, during my interview, or hiring process may result in discharge and/or legal action.
ACKNOWLEDGEMENT OF AT-WILL EMPLOYMENT
I UNDERSTAND THAT IF I AM HIRED BY ARK REGIONAL SERVICES, MY EMPLOYMENT, COMPENSATION AND/OR BENEFITS CAN BE TERMINATED WITH OR WITHOUT NOTICE, AT THE OPTION OF EITHER THE ARK OR MYSELF. I ALSO UNDERSTAND THAT NO EMPLOYEE, MANAGER, OR SUPERVISOR OF THE ARK HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT OR MAKE ANY PROMISES CONTRARY TO THIS DISCLAIMER, UNLESS SUCH AGREEMENT IS IN WRITING AND SIGNED BY THE CHIEF EXECUTIVE OFFICER. I UNDERSTAND THAT, IF I AM HIRED, NO CONDUCT OR STATEMENT, VERBAL OR WRITTEN WHICH CONTRADICTS THIS DISCLAIMER CAN CONSTITUTE AN EXPRESS OR IMPLIED CONTRACT REGARDING MY EMPLOYMENT, AND I SHOULD NOT RELY ON ANY SUCH CONDUCT OR STATEMENTS.

My typed name below shall have the same force and effect as my written signature.

Signature of Applicant: