Autism Services Center

Online Application

Employment

Thank you for your interest in Autism Services Center (ASC) as a prospective employer. Your interest in our agency and its mission is greatly appreciated. Please read the following before continuing the employment application process.

Autism Services Center is an Equal Employment Opportunity/Affirmative Action employer and is therefore subject to certain governmental record keeping and reporting requirements. Applicants, who voluntarily self-identify their race, color, sex, national origin and veteran's status, allow ASC the ability to comply with state and federal regulations.

The information gathered on this form, other than name and position for which you have applied, is for statistical and affirmative action purposes only and does not influence employment decisions. This page is separated from your application immediately upon being received, and will be kept confidential. The second half of this form is to be completed voluntarily.

Date: Position(s) of Interest: How did you learn about the position for which you are applying:

Contact Information

Street Address APT# City: State Postal Code Date

Last Name: First Name: MI: Home Phone: Work Phone: Email:

Employment Information

U.S. Citizen? Have you ever applied for employment with us? Position Desired:

*If applying for Direct Care Staff, please name the Autism Services Center employee who referred you to our agency. (If applicable)

Referred by:

Overtime Preference of Shift: Are you at least 18 years of age? Are you willing to work weekends?

Education

*Employment is subject to verification of age

	Name of Location of School	Course of Study	Yrs. Completed	Graduate	Degree/Diploma
Graduate:
College:
Bus/Trade/Tech:
High School

Membership in Professional, Community or Civic Organizations
(You may exclude those which may disclose your race, color, religion, or national origin)

Please list two (2) professional references and one (1) personal reference.

Professional Reference 1

Relationship: Company: Full Name: Phone Number:

Address: City: State: Zip Code:

Professional Reference 2

Relationship: Company: Full Name: Phone Number:

Address: City: State: Zip Code:

Personal Reference

Relationship: Company: Full Name: Phone Number:

Address: City: State: Zip Code:

Previous Employment

How many previous employers would you like to list?

Company 1

Company: Address: Job Title: Responsibilities Reason for Leaving: Hire Date: End Date:

Phone Number: Starting Salary Hr or Yr Ending Salary Hr or Yr Name of Supervisor May we contact your previous supervisor for a reference?

Company 2

Company: Address: Job Title: Responsibilities Reason for Leaving: Hire Date: End Date:

Phone Number: Starting Salary Hr or Yr Ending Salary Hr or Yr Name of Supervisor May we contact your previous supervisor for a reference?

Company 3

Company: Address: Job Title: Responsibilities Reason for Leaving: Hire Date: End Date:

Phone Number: Starting Salary Hr or Yr Ending Salary Hr or Yr Name of Supervisor May we contact your previous supervisor for a reference?

Work Availability

ASC requires each employee to be available to work a minimum of 24 hours weekly and 16 hours of weekend/overnight availability is necessary.

Hours per week you can work:

The following is a Voluntary Survey for EEO Statistical Purposes Only

Sex:

Ethnic Group:

White/Caucasian (Non Hispanic/Latino) - all persons having origins in any of the original people of Europe, North Africa or the Middle East

Black /African American - all persons having origins in any of the black racial groups of Africa

Hispanic/Latino - All persons of Mexican, Puerto Rican, Cuban, Central or South America, Spanish or Portuguese culture or origin

Native Hawaiian/Pacific Islander - any persons having origins in any of the peoples of Hawaii,Guam, Samoa, or other Pacific Islands

Asian - all persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand or Vietnam

American Indian/Alaskan Native - all persons having origins in any of the original peoples of North or South America, and who maintain cultural identification through tribal affiliation or community

Two or More Races - all persons who identify with more than one of the above races, please also mark the race with which you most identify

Military
Active

Inactive

Retired

N/A

Veteran:
Vietnam Era

Gulf War

Disabled

Other

US Reserves/Coast Guard Status

Do you have any disabilities?

If so, please indicate:

Additional Information

Please select yes or no to the following questions:

Have you ever been charged or convicted of any crime or felony? If "Yes", desribe in full. (Such convictions may be
relevant if job-related) Felony Description

Are you willing to transport clients? Do you have an automobile? Do you have auto insurance?

Disclaimer and Signature

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation ofthis application and/or separation from the employer's service if I have been employed. Furthermore, I understand that just as Iam free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without causeand without prior notice. I understand that no representative of the Employer has the authority to make any assurances to thecontrary.I give the Employer the right to investigate all references and to secure additional information about me, if job related. I herebyrelease from liability the Employer and its representatives for seeking such information and all other persons, corporations ororganizations for furnishing such information.The Employer is an Equal opportunity Employer. The Employer does not discriminate in employment and no question on thisapplication if used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited bylocal, state, or federal law.This application is current for only six (6) months. At the conclusion of this time, if I have not heard from the Employer and stillwish to be considered for employment, it will be necessary to fill out a new application.All applications become the property of Autism Services Center and are maintained in agency file for a period of six (6) months.I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature Date

Autism Services Center is a private, 501(c)(3) non-profit agency providing quality services to individuals with intellectual and developmental disabilities in Cabell, Wayne, Lincoln, Mason and Putnam counties in West Virginia. We presently serve approximately 250 individuals and employ a staff of almost 500.