The Arc Dearborn

For people with intellectual and developmental disabilities

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Employment Application

We are an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, religion, sex, origin, marital status, age or mental or physical disability in the hiring, promotion, payment, disciplining and in all other terms and conditions of employment.

Basic Information
Position Applied For
Type of Employment
- Full Time
- Part Time
- Summer
- Temporary
Name*
First Last
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Social Security Number
Phone
Are you 18 years or older?
- Yes
- No
Are you legally entitled to work in the United States?
- Yes
- No
Do you have a valid driver's license?
- Yes
- No
Have you ever been convicted of a felony or misdemeaner other than a minor traffic violation? How you answer will not preclude you from consideration for emplyment.
- Yes
- No
Please describe the felony or misdeanor.
Education
High School attended and location.
Graduated?
- Yes
- No
University attended and location.
Number of years completed.
Graduated?
- Yes
- No
Degrees
Master subjects of specialization.
Community college attended and location.
Number of years completed.
Graduated?
- Yes
- No
Degrees
Master subjects of specialization.
Other Educational Training/Courses
Employment History (List present or most recent positions first)
Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Business
Department
Your Position
Duties
Name and Position of Immediate Supervisor
Date Employed
Date Format: MM slash DD slash YYYY
Date Left
Date Format: MM slash DD slash YYYY
Starting Salary
Final Salary
Reason for Leaving
Name of Employer 2
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Business
Department
Your Position
Duties
Name and Position of Immediate Supervisor
Date Employed
Date Format: MM slash DD slash YYYY
Date Left
Date Format: MM slash DD slash YYYY
Starting Salary
Final Salary
Reason for Leaving
Name of Employer 3
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Business
Department
Your Position
Duties
Name and Position of Immediate Supervisor
Date Employed
Date Format: MM slash DD slash YYYY
Date Left
Date Format: MM slash DD slash YYYY
Starting Salary
Final Salary
Reason for Leaving
May we contact your current employer for a reference?
- Yes
- No
May we contact your previous employers for a reference?
- Yes
- No
Will you be able to perform the essential functions of the position for which you are being considered?
- Yes
- No
References (Please do not list relatives)
Reference 1
First Last
Occupation
Phone
Reference 2
First Last
Occupation
Phone
Reference 3
First Last
Occupation
Phone
Other
Activities/Interests (Student, Professional, Community, etc.)
Other interests or hobbies
Special talents
Additional Remarks
We appreciate your interest in seeking employment with us. Please feel free to make any additional remarks in the space provided above that would be helpful in evaluating your qualifications.

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The Arc Dearborn
22450 Park Street
Dearborn, MI 48124

Phone 313.562.1787
Fax 313.562.0387

info@thearcdearborn.org

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