ACT Alternative Community Training

2200 Burlington
Columbia, MO  65202
1-800-359-4607
TDD 573-474-1199
Contact ACT

Application for Employment

 
Contact Information (* indicates a required field, please)
  *
 
       
 

Soc. Security No. *

Phone # with Area Code *  
   
       
  Address * City * State * Zip *
 
       
  Position Applied For *
 
       
       
 


Employment History
Begin with current or last job. Include military service assignments.
If you include volunteer activities, you may exclude organizations that indicate race, color, religion, national origin, disability or other protected status.
  Employer * Title Hourly Wage/Salary
 
  Start Date End Date Supervisor
 
  Duties    
 
  Reason for leaving    
 
 
  Employer Title Hourly Wage/Salary
 
  Start Date End Date Supervisor
 
  Duties    
 
  Reason for leaving    
 
 
  Employer Title Hourly Wage/Salary
 
  Start Date End Date Supervisor
 
  Duties    
 
  Reason for leaving    
 
       
       
 
Education
       
  High School Location Diploma/Degree *
 
       
  Trade/Professional Location Diploma/Degree
 
       
  College/University Location Diploma/Degree
 
       
  Graduate School Location Diploma/Degree
 
       
       
 
Specialized Training, Apprenticeship, Extracurricular Activities:
 
       
  Job-Related Skills/Qualifications from Employment or Experience:
 
       
 

Professional, Trade, Business or Civic Organizations/Offices:
YOU MAY EXCLUDE ORGANIZATIONS THAT INDICATE RACE, COLOR,
RELIGION, NATIONAL ORIGIN, DISABILITY OR OTHER PROTECTED STATUS.
 
       
       
 
Military History
  When Branch Release/type
 
  Job-related training    
 
  Current status    
     
       
       
 
  Yes / No      
    If under 18 years of age, can you provide proof of eligibility
to work?
         
   

Have you ever applied to ACT before?
If yes, when?
         
   

Have you ever been employed by ACT?
If yes, when?
         
   

Were you referred by a relative or friend employed by ACT?If yes, who?
         
    May we contact your present employer?
         
   

Have you ever been convicted of a crime
(other than a traffic violation)?
Conviction will not necessarily disqualify you
from employment. If yes, please explain: *

         
    Do you have a valid Missouri driver's license? *
         
   

Have you ever been ticketed for a moving traffic violation?
If yes, please explain:
       
    Are you legally eligible to work in the United States? Upon
hiring, two forms of proof must be provided: Visa, green
card, Social Security card, or driver's license. *
       
    Are you currently on "layoff" status, subject to recall?
       
   

Have you ever had a substantiated charge of abuse
or neglect against you? If yes, explain: *

       
       
 
On what day will you be available for work?
 
       
 

Full Time Only
Full Time or Part Time
Temporary

 What hours would you be available to work? (be specific)
 
 
       
       
 
Four References Other than Previous Employers or Relatives
  Name * Telephone * Address *
 
  Name Telephone Address
 
  Name Telephone Address
 
  Name Telephone Address
 
       
       
 
AFFIRMATIVE ACTION QUESTIONNAIRE

The management shall not fail to hire, discharge or discriminate among applicants for
employment or employees in terms of compensation, terms, conditions, and privileges
of employment because of race, color, religion, national origin, sex, disability status,
age, or disabled and Vietnam-era veterans. Reasonable accommodation shall be
made for persons with disabilities who are applicants and employees capable of performing
the essential qualification of their positions. This facility shall not limit, segregate
or classify applicants and employees so as to tend to, or to deprive, any applicant
or employee of employment opportunity or adversely affect the employment opportunity
of such persons.

To help us analyze our recruitment policy, we request that you voluntarily complete this
questionnaire. The information you supply will be kept confidential and will be used
only for affirmative action purposes. Your choice not to respond will not adversely
affect your employment opportunity since the information is not part of our personnel system.
       
  Name (optional) Birth Date Sex
 
  Race Age  
   
 
Disability Definition: A disability means a physical or a mental impairment that substantially limits a
major life activity so that an employee has difficulty in maintaining or advancing
in employment without reasonable accommodation being made for the person.
Included in the definition are: Persons with a disability, persons with a record of
a disability, and persons considered to have a disability.
  Do you have a disability?
       
  Disabled Veteran Definition: A disability compensation rated at 30% or more or discharged for a disability incurred or aggravated in the line of duty.
  Are you a disabled Veteran? If yes, what is your disability rating %
     
  Vietnam-era Veteran Definition: A person on active duty for more than 180 days (or discharged for a serviceconnected disability), and any part of the duty occurred between August 5, 1964
and May 7, 1975, and with other than a dishonorable discharge. A less than
honorable discharge will not be an absolute bar to employment, but will only be
considered in relation to specific job requirements.
  Are you a Vietnam-era Veteran?
       
  Referral Source Date of Application  
   
       
       
 


APPLICANT'S ACKNOWLEDGMENT
(This application shall be considered active for no more than 45 days. After that time,
applicants will be required to resubmit a completed application. The applicant understands that neither this document nor any offer of employment from this employer constitutes an employment contract unless a specific document is executed in writing by the employer and employee.)

I certify that answers given in this application are true and complete to the best
of my knowledge. I authorize investigation into all statements I have made on this
application as may be necessary for reaching an employment decision.
In the event I am employed, I understand that any false or misleading information
I knowingly provided in my application or interview(s) may result in discharge
and/or legal action. I understand also that if employed, I am required to abide by all
rules and regulations of the employer and any special agreements reached between
the employer and me. I understand that employment is contingent on a clear record
as reported by the Department of Mental Health and other State bureaus.

This Agency utilizes several resources in order to hire the most appropriate applicants. Non-disqualifying results of pre-employment checks are some of the requirements for
employment with ACT. These checks include, but are not limited to:
1. Criminal Record Check
2. Department of Mental Health Background Check
3. Child Abuse/Neglect Registry
4. Division of Aging Background Check
5. Pre-Employment Drug Screening
6. Motor Vehicle Report
All checks are conducted post-offer, pre-employment.