Online application form - 7TH & Madison

Phone

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Employer Information

Employer:	7TH & Madison Extensions of Empowerment
Address:	211 Warren Street, Suite 223
City/State/ZIP:	Newark, New Jersey, 07103
Telephone:	(800) 936-3256

It isthe policy of 7TH & Madison Extensions of Empowerment to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

2. Applicant Information

Applicant Full Name:

Home Address:

City/State/ZIP:

Number of years at this address:

Daytime phone:

Mobile phone:

Date of Birth:

Social Security Number:

Driver's License (State/Number):

3: Emergency Contact

Who should be contacted if you are involved in an emergency?

Contact Name:

Relationship to you:

Address:

City/State/ZIP:

Daytime phone:

Evening phone:

4. Job Position Applied For:

Full or Part Time?

5: Salary Desired:

6: Who referred you to our company?

Do you have any friends or relatives who work here? If yes, please list here:

7: Have you applied to our company previously?

Yes
No

If yes, when?

8: Are you at least 18 years old?

Yes
No

9: How will you get to work?

10: Are you willing to work any shift, including nights and weekends?

Yes
No

If no, please state any limitations:

11: If applicable, are you available to work overtime?

Yes
No

12: If you are offered employment, when would you be available to begin work?

13: If hired, are you able to submit proof that you are legally eligible foremployment in the United States?

Yes
No

14: Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?

Yes
No

What reasonable accommodation, if any, would you request?

15. Applicant's Skills

Check those skills that you have. List any other skillsthat may be useful for the job you are seeking. Enter the number of years of experience and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

Skills

Typing

Years of Experience

Ability or Rating

1
2
3
4

Microsoft Office Suite (Word, Excel, etc.)

Years of Experience

Ability or Rating

1
2
3
4

Accounting/Bookkeeping

Years of Experience

Ability or Rating

1
2
3
4

Answering telephones

Years of Experience

Ability or Rating

1
2
3
4

Filing

Years of Experience

Ability or Rating

1
2
3
4

Customer service

Years of Experience

Ability or Rating

1
2
3
4

Experience In working with someone with a disability

Years of Experience

Ability or Rating

1
2
3
4

16. Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gapsin employment. If additional space is needed, continue on the back page of this application.

Employer Name:

Supervisor Name:

Address:

City/State/ZIP:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Employer Name:

Supervisor Name:

Address:

City/State/ZIP:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

Employer Name:

Supervisor Name:

Address:

City/State/ZIP:

Job Duties:

Reason for Leaving:

Dates of Employment (Month/Year):

17. Applicant's Education and Training

College/University Name and Address

Did you receive a degree?

Yes
No

If yes, degree(s) received:

High School/GED Name and Address

If yes, degree(s) received:

Other Training (graduate, technical, vocational):

Please indicate any current professional licenses or certifications that you hold:

Awards, Honors, Special Achievements:

Military Service:

Yes
No

Branch:

Specialized Training:

18. References

List any two non-relatives who would be willing to provide a reference for you.

Name:

Address:

City/State/ZIP:

Telephone:

Relationship:

Name:

Address:

City/State/ZIP:

Telephone:

Relationship:

19. Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

Statement of Attestation: I, the applicant, attest, I have not been convicted of any crimes or offenses.

CERTIFICATION

I certify that the information provided on this application istruthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination

I authorize 7TH & Madison Extensions of Empowerment to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizationsto fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated asreferences to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Director, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of 7TH & Madison Extensions of Empowerment, except in a specific written contract of employment signed on behalf of the organization by its Director, hasthe power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

APPLICANT SIGNATURE (wet signature)

DATE

APPLICANT PRINT NAME

CAPTCHA

EMPLOYMENT APPLICATION

Employer Information

3: Emergency Contact

15. Applicant's Skills

Skills

16. Applicant Employment History

17. Applicant's Education and Training

18. References