Employment Application - 1st Cerebral Palsy of New Jersey

Position You Are Applying For*

Desired Salary*

First Date Available For Work*

MM

DD

YYYY

Personal Information

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

Email

Are You a U.S.A. Citizen?*

Yes
No

Agree to Testing*

If applicable, are you willing to complet a drug screening test, criminal history check, New Jersey driver's license check, and merical screening if selected for employment?

Yes
No

Education

School Name	Location	Years Attended	Degree Received	Major

Other training, certification(s), or licenses held:

Employment

Employer

Date Started

MM

DD

YYYY

Date Started

MM

DD

YYYY

Address

Phone

Fax

Position

Pay Rate

Supervisor's Name

May we contact them?

Yes
No

Reason For Leaving

Employer

Date Started

MM

DD

YYYY

Date Ended

MM

DD

YYYY

Address

Phone

Fax

Position

Pay Rate

Supervisor's Name

Reason For Leaving

May we contact them?

Yes
No

Professional References

Name	Relationship	Complete Address	Phone Number

Are you related to any current employees of 1st Cerebral Palsy of New Jersey, Inc.*

Yes
No

Have you been employed by 1st Cerebral Palsy of New Jersey, Inc or Cerebral Palsy of Essex & West Hudson in the past?*

Yes
No

How did you learn about our agency or this program?

Terms and Conditions

1st Cerebral Palsy of New Jersey, Inc. prides itself on being an equal opportunity employer. We will not discriminate in employment because of sex, age, race, physical disability, religion, ethnicity, mental disability, marital status, ancestry, sexual orientation, place of origin or any other legally protected status.

In consideration of employment, I agree to confirm to the policies, procedures and practices of 1st Cerebral Palsy of New Jersey. My employment and compensation can be terminated, with or without cause, and with or without notice, at any time at the option of the agency or myself. Any exceptions to this policy may only be made in writing and signed by the Board of Trustees of 1st Cerebral Palsy of New Jersey, Inc.

I understand that no part of this application is intended to imply or create an employment relationship. Further, this application is not a contract for employment*

I certify that all answers given herein are true and complete to the best of my knoweldge
I authorize the investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.