Sep 7
Application for Employment

  1. Personal Information

  2. First Name(*)
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  3. Middle Name
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  4. Last Name(*)
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  5. Address(*)
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  6. City(*)
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  7. State(*)
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  8. Zip Code(*)
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  9. Home Phone(*)
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  10. Cell Phone
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  11. Today's Date
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  12. Availability

  13. Please check everything you wish to be considered for:(*)






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  14. *Day Staff work between 6:30 a.m. - 5 p.m.

  15. Position Desired

  16. Please check the position(s) you wish to apply for:(*)




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  17. Other Position Desired:
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  18. Minimum Qualifications

    (vary depending on position being sought - please see job description for complete list of minimum qualifications)
  19. For all applicants:
  20. Are you legally able to be employed in the United States of America?(*)
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  21. You must be at least 18 years of age to be employed by the Work Activity Center. Are you at least 18 years old?(*)
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  22. Do you have reliable transportation to and from work?(*)
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  23. For positions requiring driving:(Note-Individuals who regularly drive Center vehicles will be required to pass a UDOT physical exam.)
  24. Are you 21 years or older? (required to drive Center Vehicles)
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  25. Do you have a valid and current Utah Driver’s License?
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  26. Additional Information

  27. Have you ever worked at the Work Activity Center before?(*)
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  28. If yes, what dates were you employed?
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  29. If yes, what was your name while you were employed?
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  30. Do you have any relatives employed at the Center?(*)
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  31. If yes, who?
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  32. How did you hear about this organization? (Select all that apply)
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  33. Name of Family/Friend (if applicable)
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  34. Online Job Board Website (if applicable)
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  35. Applicable Volunteer Experience —Please list any volunteer experience relating to people with disabilities.
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  36. Education

  37. 1. High School Name
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  38. City and State
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  39. Major
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  40. Diploma/GED(*)
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  41. 2. School Name
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  42. City and State
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  43. Major
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  44. Degree Earned
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  45. 3. School Name
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  46. City and State
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  47. Major
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  48. Degree Earned(*)
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  49. Work History

    Please list your last 3 job positions beginning with your most current employment.
  50. May we contact your previous employers?(*)
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  51. If employment was under a different name, please indicate name:
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  52. 1. Name of Company
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  53. Phone Number
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  54. City and State
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  55. Name of Supervisor
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  56. Work Dates: From
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  57. To
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  58. Reason for Leaving
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  59. Position Title
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  60. Duties
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  61. Wage Upon Leaving
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  62. Hourly/Annually
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  63. ____________________________________________________________
  64. 2. Name of Company
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  65. Phone Number
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  66. City and State
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  67. Name of Supervisor
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  68. Work Dates: From
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  69. To
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  70. Reason for Leaving
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  71. Position Title
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  72. Duties
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  73. Wage Upon Leaving
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  74. Hourly/Annually
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  75. ____________________________________________________________
  76. 3. Name of Company
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  77. Phone Number
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  78. City and State
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  79. Name of Supervisor
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  80. Work Dates: From
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  81. To
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  82. Reason for Leaving
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  83. Position Title
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  84. Duties
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  85. Wage Upon Leaving
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  86. Hourly/Annually
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  87. Work Related References

    Please list three work related references other than those listed above who we can contact to verify employment:
  88. 1. Name
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  89. Company
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  90. Phone Number
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  91. Relationship
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  92. 2. Name
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  93. Company
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  94. Phone Number
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  95. Relationship
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  96. 3. Name
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  97. Company
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  98. Phone Number
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  99. Relationship
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  100. Training, Certifications or Licenses

    Please list any additional trainings in the space provided below. Some examples include CPR, First Aid, Food Handlers Permit, SOAR or MANDT, CNA license, etc.
  101. List all here
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  102. Conviction Disclosure

  103. Have you ever been convicted of anything other than a minor traffic violation?(*)
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  104. If yes, please list all convictions along with dates and final disposition plus all cases pending:
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  105. Most convictions will not automatically disqualify an applicant for an offer of employment. The seriousness, date of conviction, and relation to the type of work conducted at the Center will be considered. The Work Activity Center conducts a background and criminal investigation check on all persons employed. This search is comprehensive and includes juvenile records.

  106. Please complete the following statements and sign the form.

  107. My last employer would say that I am best at:(*)
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  108. My last employer would say that I need to work on:(*)
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  109. At work, the things that I would like to improve on are:(*)
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  110. The one thing that makes me an outstanding employee is:(*)
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  111. EQUAL OPPORTUNITY, DISCRIMINATION, AND AFFIRMATIVE ACTION POLICY

    The Work Activity Center is an equal opportunity employer and does not discriminate against any persons on the basis of race, color, religion, national origin, sex, age, or disability. The Work Activity Center opposes and will not tolerate discrimination, including harassment, by or against any employees or participants in the Center’s services. The Work Activity Center does not discriminate against the above mentioned protected classes in making decisions regarding hiring, firing, training, discipline, compensation, benefits, classification, advancement or other terms of employment.

  112. Accept These Terms(*)
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  113. POLICY ON DRUG-FREE WORKPLACE

    In accordance with the Drug-Free Workplace Act of 1988, the Work Activity Center’s policy is: The unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance in the Work Activity Center’s business on or off the property is prohibited. Violation of this policy will result in disciplinary action including possible termination of employment and possible legal consequences. As a condition of employment at the Work Activity Center, all applicants/employees are drug-tested at or shortly after the time of hiring. If you test positive for drug use, employment may be terminated immediately.

  114. Accept These Terms(*)
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  115. Your signature below indicates: 1. That you understand and agree to abide by the Work Activity Center’s Drug Free Workplace policy as a condition of employment; 2. That you authorize the Center to obtain and view summaries of any criminal histories that may exist concerning you from appropriate state and federal agencies for the limited purpose of considering you for employment with the Center and; 3. That you certify that all information furnished on this application form is accurate and complete to the best of your knowledge and belief. Also, that you understand that any misrepresentation or omission of fact, as stated and/or implied, on this application form or any other employment form is sufficient reason not to hire you or may be reason for dismissal. 4. That you understand that employment with Work Activity Center is at will, meaning that either the Employee or the Employer can terminate employment at any time, with or without notice, for any reason not prohibited by law.

  116. Signature (full name)(*)
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  117. Email Address(*)
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