Join Us - Employment Application

BRISTOL ADULT RESOURCE CENTER, INC.
621 Jerome Avenue, P.O. Box 726
Bristol, CT 06011-0726
Phone: (860) 582-9102 ~ Fax: (860) 582-8280
Email: bristolarc@bristolarc.org

~ Agency policy requires all applicants be at least eighteen years of age. ~
~ We are an affirmative action agency and an equal opportunity employer. ~

~ Employment with the Bristol Adult Resource Center, Inc. is on an at-will basis, which means that your employment
and compensation can be terminated, at any time, at the option of either the agency or you. ~

Click here for a printable version or fill out the form below.

General Information
Name:	Home Phone/Cell No.:	Date:
Email:

Position(s) applied for:	1)	Full Time	Part Time
	2)	Full Time	Part Time
Specify days and hours you would be available to work:

Present Address:

No. Street

City

State

Zip

Previous Address:

No. Street

City

State

Zip

Referred by:	Employee Newspaper	Name of Paper:
	Agency Job Service	Other:
Do you have the right to work in the United States?		Yes No

Have you ever been interviewed by us?	Yes No	If yes, when?
Were you previously employed by us?	Yes No	If yes, when?

List any friends or relatives working for us:	Name	Relationship
	Name	Relationship

Do you have a valid drivers’ license?

Yes No

What State?

Have you ever been convicted of a crime?

Yes No

If yes, please explain:

"Conviction" for this application, means a final judgment or verdict of guilty, a plea of guilty, or a plea of nolo contendere, in any state or federal court, regardless of whether an appeal is pending or could be taken.

"Conviction" does not include a final judgment or verdict that has been expunged by pardon, reversed, set aside or otherwise rendered invalid. Further, you are not required to disclose any arrest(s), criminal charge(s) or conviction(s) the record(s) of which have been erased under law. Such records can include records of a finding of delinquency or that a child was a member of a family with service needs, adjudication of youthful offender status, criminal charges dismissed or nolled, or charges for which a person is found not guilty or a conviction later resulting in an absolute pardon.

Further, any person whose criminal records have been erased is deemed under law never to have been arrested with respect to such erased proceedings and may so swear under oath.

A history of criminal conviction(s) will not necessarily bar consideration of employment. Factors such as the time, seriousness and nature of the offense, as well as rehabilitation, will be taken into account.

Should you have any question about answering questions on this application, or your rights concerning erased records, please inquire of the Human Resource Manager.

Are there any criminal charges currently pending against you?

Yes No

If yes, please explain:
Education:
Elementary School:
High School:
Diploma or GED:	Yes No

If the position(s) you are applying for does/do not require a degree, completing the following information is optional:
College:		Dates Attended: From: To:
College:		Dates Attended: From: To:
Major:		Degree or Certificate:

Record Of Employment Beginning With Most Recent:
Name and Address of Company:
Date Employed: From (mo/yr):	To (mo/yr):
Position and Basic Duties:
Reason for Leaving:
Name and Address of Company:
Date Employed: From (mo/yr):	To (mo/yr):
Position and Basic Duties: /td>
Reason for Leaving:
Name and Address of Company:
Date Employed: From (mo/yr):	To (mo/yr):
Position and Basic Duties:
Reason for Leaving:

*Are there any other experiences, skills, or qualifications which you feel make you especially competent for work with the Bristol Adult Resource Center, Inc.?

References: Work related only – supervisor preferred. “No family members.” If you are called for an interview, references you list may be contacted.

Name	Position	Business	Telephone Number

Name	Position	Business	Telephone Number

Name	Position	Business	Telephone Number
What date would you be available to start work?

RELEASE OF INFORMATION FORM

I, , do hereby give permission for the release of any and all information from employment, education, and personal references to the Bristol Adult Resource Center for the sole purpose of conducting an employment check for the position of .

Signature (Entering your name here is equivalent to a signed signature)

Date

*THE FOLLOWING INFORMATION MUST BE COMPLETED:

I understand that it will be necessary for Bristol Adult Resource Center, Inc. to conduct a police check for recent drug related convictions or criminal activity. I also understand that it will be necessary for Bristol Adult Resource Center, Inc. to check my driving record and medication certification record when applicable.

In order to conduct the police check, motor vehicle report, and medication certification verification, it is necessary for us to have your date of birth, middle initial, maiden name (if applicable), Social Security No., driver’s license no., state license issued, and driver’s license expiration date.

Date of Birth:		Middle Initial:
Maiden's Name:	(if applicable)	Social Security No.:
Driver's License No.:	State Issued: Expiration Date:

Falsification of any item on this employment application will be grounds for immediate dismissal!
Applicant Authorization:
	Signature (Entering your name here is equivalent to a signed signature)	Print Name	Date

AFFIRMATIVE ACTION - APPLICANT LOG

The following information is voluntary and will be used for statistical purposes only.

The Bristol Adult Resource Center, Inc., is an affirmative action agency and an equal opportunity employer.

Please check appropriate box:
	Caucasian:	Male
	African American:	Female
	Hispanic:
	Other:

Are you a veteran of a foreign war? Yes No

If so, what war did you serve in?

Name:		Date Applied:
Address:		Phone Number:

Position(s) Applied For:	1)
	2)
Referred By:	Employee Newspaper Name of Newspaper:
	Agency Dept. of Labor website Other