Application for Employment 1 2 Application Must be Completed in Full for ConsiderationName* First Middle Last Position Applied For*If you'd like to apply for any other positions, please list them herePlease be specificSalary Desired*Type of Employment Desired (listed on job posting)* Full Time Part Time On Call On-Call Employees at Emerge work at either our emergency shelter or at our hotline location. Shift coverage may be needed when full- or part-time employees are out due to scheduled leave, or unexpected absences or while positions are being filled. On-Call employees may know what shifts they will be working with advance notice (up to 2 or 3 weeks). It also may be the case that On-Call employees are notified of same day shifts available in the event of an unexpected absence. On-Call employees are not guaranteed work shifts, and the existence and frequency of on-call utilization is strictly subject to the shift coverage needs of Emerge. On-Call employees are expected to work a minimum of one (1) shift per week. Please indicate which days & shifts you would be available to work below.*Hold the CTRL/CMD key to select multiple items.Sun 7:30am-4:00pmSun 3:00pm-11:30pmSun 10:00pm-8:00amMon 7:30am-4:00pmMon 3:00pm-11:30pmMon 10:00pm-8:00amTues 7:30am-4:00pmTues 3:00pm-11:30pmTues 10:00pm-8:00amWed 7:30am-4:00pmWed 3:00pm-11:30pmWed 10:00pm-8:00amThurs 7:30am-4:00pmThurs 3:00pm-11:30pmThurs 10:00pm-8:00amFri 7:30am-4:00pmFri 3:00pm-11:30pmFri 10:00pm-8:00amSat 7:30am-4:00pmSat 3:00pm-11:30pmSat 10:00pm-8:00amI need to give notice to my current employer*YesNoHow much notice do they request?*I could be available to start on*How did you learn about our agency and/or positions?*Recruiting/jobing.comIndeedUAASUPima Community CollegeEmerge WebsiteEmployee ReferralName of Employee*Have you previously applied for a job at Emerge?*YesNoIf yes, please state the date of your last applications*Have you previously been employed by Emerge?*YesNoIf yes, please state what date you were employed*The position you are applying for may require you to work hours in addition to the schedule posted. Are you able to work hours in addition to the posted schedule?*YesNoIf no, please explain*Have you ever been disciplined for violating company rules or regulations?*YesNoIf yes, please explain*Use the space below to describe why you are interested in working for our agency.*Work HistoryYour Resume is Not a Substitute for Completing the Following (except where noted). List your most recent employer first. Account for at least 10 years post high school (as applicable) including military service and any periods of unemployment. Employer OneYour current or most recent employerDates Employed (mm/yy-mm/yy)City, StatePhone NumberMay we Contact?Your SupervisorIndustry/Business TypeYour TitleAverage Hours Worked/WeekWhat did you do in this job?(If your resume specifies this information, please attach it at the end of this form and you may leave this portion blank.)Reason for LeavingCurrently Employed?YesNoEmployer TwoYour Previous EmployerDates Employed (mm/yy-mm/yy)City, StatePhone NumberMay we Contact?Your SupervisorIndustry/Business TypeYour TitleAverage Hours Worked/WeekWhat did you do in this job?(If your resume specifies this information, please attach it at the end of this form and you may leave this portion blank.)Reason for LeavingWould you like to list a third employer?YesNoEmployer ThreeYour Previous EmployerDates Employed (mm/yy-mm/yy)City, StatePhone NumberMay we Contact?Your SupervisorIndustry/Business TypeYour TitleAverage Hours Worked/WeekWhat did you do in this job?(If your resume specifies this information, please attach it at the end of this form and you may leave this portion blank.)Reason for LeavingWhich of these jobs did you like the best?What did you like the most about this job?EducationDo you have a high school diploma or GED?*YesNoHigher degrees you may have earned*Associate/Bachelor/Master/PhDDid you Graduate?Name of SchoolProgram or Area Studied, Degree Major/Minor Other Professional Education you may have completed(which is relevant to the position you are applying for)Name of SchoolProgram or Area StudiedDiploma or Certificate Earned Volunteer ExperiencePlease list any relevant volunteer experience. Please do not list experience which may be protected by City, State or Federal laws/regulations.Name of Agency/GroupDatesTypes of Tasks/Duties Please list skills/certifications/licenses you have which are pertinent to the position for which you are applying:To provide the highest level of services for our clients, Emerge ensures we have employees who are fluent in Spanish. On occasion, we may also have clients who need assistance in other languages. Please respond to the following questions to help us understand what languages in which you’re fluent. If the position you are applying for does not require you to be bilingual (English / Spanish), your responses to these questions will not disqualify you. Can you speak Spanish fluently?*YesNoCan you read Spanish?*YesNoCan you write in Spanish?*(These skills will be assessed during the hiring process) YesNoAdditional Languages read, written or spoken fluently other than English and Spanish:Please provide a personal statement in this space outlining how your work and life experience directly prepare you to meet the required qualifications listed on the job posting for the position for which you are applying. Please note: it is not requested or necessary to give details of personal experiences; please focus on how your experiences prepare you for the role you are applying for.*Professional ReferencesPlease list individuals who can speak to your work experience. Please do not list family members or friends.1st Reference*NamePhone NumberEmail AddressRelationship2nd Reference*NamePhone NumberEmail AddressRelationship3rd Reference*NamePhone NumberEmail AddressRelationshipSignature*I certify that information provided in this application is true and correct to the best of my knowledge. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews may be grounds for termination. I hereby authorize Emerge to contact any company or individual it deems appropriate to confirm my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this process and follow-up. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements. If employed, I agree to abide by the policies and procedures of Emerge I also understand that my employment is “at-will” and may be terminated by myself or by the agency at any time for any reason or no reason at all, with or without prior notice. I further understand that only the CEO has the authority to make any agreement contrary to “at-will”. Personal InformationThis information will be kept confidential and separate from your completed application.Name* First Middle Last Main Contact #*Alternate Contact #Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you 18 years of age or older?*YesNoDo you have the legal right to be employed in the U.S.?*YesNoHave you ever been convicted of any crime (excluding minor traffic violations), including driving while under the influence of alcohol or drugs?*YesNoIf yes, please explain:*Do you have a valid Driver’s License?*Most positions at Emerge require driving on agency business, at some point in time, either in an agency vehicle or a personal vehicle (mileage reimbursed). Proof of current insurance will be required upon employment.YesNoDo you have any restrictions on your license which would prevent you from driving an agency vehicle or on agency business?*YesNoIf yes, please explain:*Do you have a current fingerprint card and/or CPR card?* I have a current fingerprint card I have a current CPR card Are you aware of any restrictions you may have on a current fingerprint card OR would be implemented when an application is submitted for fingerprint clearance?*YesNoPhoneThis field is for validation purposes and should be left unchanged.