Job Application

GHA Autism Supports participates in E-Verify -- Federal Law requires all employers to verify the identity and employment eligibility to all persons hired to work in the United States.

Resume` Upload (Optional) Resume` must be .PDF (Adobe) or .DOC (Word)

Type your legal name as it appears on your Social Security Card

First Name *

Middle/Maiden Name

Last Name *

Home Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Mailing Address (If different than your home address)

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Today's Date *

Primary Phone *

Other Phone

Email Address (Optional)

How do you prefer to be contacted?

What position are you applying for? *

Shift Desired *

1st2nd3rdAny available

Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States? *

YesNo

Are you available for:

*All direct support employees may work schedules that include weekend and holiday hours.Full-TimePart-TimeSubstitute

Specify Days & Hours Available

Are you under 18 years of age? *

NoYes

**Position requires valid driver's license and basic computer knowledge.

Do you possess a valid driver's license? *

YesNo

Are you insurable? *

YesNo

Driver's license number *

State (Driver's license issued) *

Driver's license expiration date *

Do you have basic computer knowledge? *

YesNo

Can you show proof of your eligibility to work in the United States? *

YesNo

Have you lived in NC continuously for the past 5 years? *

YesNo

How were you referred? *

AdvertisementFriendWebEmployment Security CommissionOther

Were you previously employed by GHA? *

YesNo

If Yes, when?

What position?

If related to anyone employed by GHA, served by GHA, or who serves on our Board of Directors, give their name and site location:

Have you ever been convicted of a crime? *

**A "Yes" answer may or may not disqualify you from employment depending on the position applied for.YesNo

If you have been convicted of a crime, please give date and details.

Are you able to perform the "essential job functions" required of the position for which you are applying, (with or without reasonable accommodation)? *

YesNoWill need further information regarding "essential job functions"

List other skills or qualifications:

Do you have a high school diploma or GED? *

DiplomaGED

High School Name and Location (city/state)

Years completed

College Name and Location

Years completed

Diploma or Degree

DiplomaDegree

Major course of study

School of Nursing - Name and Location

LPN/RN/BSN/MSN

LPNRNBSNMSN

Describe specialized training, skills, extracurricular activities, etc.

Any other training or education including military:

Military Services - Did you serve in the United States Armed Services? *

YesNo

Branch:

Dates of Service:

Type of Discharge:

Duties:

May we contact your present employer? *

YesNo

Present/Last Employer

Present/Last Employer Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Employed From - To (Month/Year)

Your Title or Position

Name of Last Supervisor

Reason for Leaving

Rate of Pay

Previous/Last Employer

Previous/Last Employer Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Employed From - To (Month/Year)

Your Title or Position

Name of Last Supervisor

Reason for Leaving

Rate of Pay

Previous/Last Employer

Previous/Last Employer Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Employed From - To (Month/Year)

Your Title or Position

Name of Last Supervisor

Reason for Leaving

Rate of Pay

Give the names of three (3) business or personal references NOT related to you.

Name *

Occupation *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone *

Years Known *

Name *

Occupation *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone *

Years Known *

Name *

Occupation *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone *

Years Known *

Licensure: (To be completed by registered professional and certified technical applicants only.) For purposes of this section, references to the term "licensed" also apply to the terms "registration" and "certification".

Medical Specialty:

State:

Expiration Date:

Certificate Number:

Serial Number:

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR 30 DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

READ CAREFULLY BEFORE SUBMITTING: I certify that the facts set forth in my application for employment are true, complete and correct. I understand that if employed, false statements on this application shall be considered sufficient cause for involuntary termination. You are hereby authorized to make any investigation of my personal, financial, employment history and work record through any credit agencies or bureaus of your choice. You are hereby authorized to make any investigation of my personal, financial, employment history and work record through any credit agencies or bureaus of your choice. I understand that if I am hired that the rules and regulations of this employer, and any personnel procedures, do not constitute a contract of employment. I understand that all employees of GHA are employed at will and that my employment and compensation can be terminated, with or without cause, and with or without notice, at anytime, at the option of either the employer or myself. I understand that if hired, I must undergo a drug screen. I further understand that no supervisor or representative of GHA other than the Chief Executive Officer or his/her designee has any authority to enter into any offer for employment. GHA is an equal opportunity employer. All employment decisions are made without regard to race, color, religion, gender, sexual orientation, age, genetic information, national origin, disability, Vietnam era status or any other basis prohibited by law.

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, age, disability, religion, sex, familial status, sexual orientation, and reprisal. (Not all prohibited bases apply to all programs). To file a complaint of discrimination, write to: USDA, Assistant Secretary for Civil Rights Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, S.W., Stop 9410 Washington, DC 20250-9410 Or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.

GHA Autism Supports

Application for Employment

Educational Record

Prior Work History (List in order, last or present employer first)

Character References

Verification