EMPLOYMENT APPLICATION

UCPRI is an equal opportunity employer~Federal & State laws prohibit discrimination against job 

To be considered for employment ~ you must read and answer all questions completely.

PERSONAL INFORMATION  
name
            last             first         middle initial
address
       # and street                  city              state       zip
phone            SSN
Are you over the age of 18? Over 18         Not over 18
Are you legally able to work in the United States, and have proof of this? Yes    No  
Do you have a valid drivers license? Yes    No
               license #
Do you currently have liability Insurance? Yes    No  

Insurance Company Name  

 
Are you willing to provide those you support with transportation inside your vehicle? Yes    No
Do you have any driving restrictions? Yes    No   

 

 

 If yes, list them here
Do you have any limitations that may inhibit your ability to perform the duties onteh job description for which you are applying? If yes, list them here
Have you ever been convicted of a felony? Yes    No  If yes, list them here
     
JOB INTEREST  
position desired   wage expected
     (specify per year, month, hour, etc)
You would be available to start on what date?
Are you available for additional hours as necessary? Yes    No
Have you ever been employed by UCPRI before? Yes    No
Do you have relatives or friends working for UCPRI? Yes    No
if yes, please name
EDUCATION  
Select the highest grade completed in each category:
grade school
high school
college
graduate school   
1-5   6 7 8
9 10   11 12  
1 2 3 4
1 2 3 4

Added comments

 Please state the hours of your availability
  from to 3rd?
sun
mon
tue
wed
thurs
fri
sat
  name location degree
high school
college
grad school
other training 

EMPLOYMENT HISTORY  
Start with the most recent employer fully disclosing all previous full time positions that you have held over the past ten (10) years.  Failure to do so may result in disciplinary action - should you be hired.
 
Company Phone # Supervisor From Mo/Yr To Mo/Yr last pay rate
Briefly Describe: reason for leaving
  job duties
  job title
           
Briefly Describe: reason for leaving
  job duties
  job title
     
Briefly Describe: reason for leaving
  job duties
  job title
     
Briefly Describe: reason for leaving
  job duties
  job title
Please discuss any occupations, including work at home or schooling which may explain any gaps in your employment history
REFERENCES (please do not include relatives)  
List, here, any employers you do not wish to have contracted and why:
name phone# Relationship Years known
STATEMENT  
I understand that this application for employment shall be considered active for no longer than 45 days, and that beyond that time if I further wish to be considered for employment I must reapply.

I hereby voluntarily give UCPRI permission to investigate all the information on this application and to contact any previous employer or other reference provided, except as where noted.

I understand that any false statement or omissions on this application constitute sufficient cause of immediate termination of employment at any time. I understand and agree that if I should accept employment at UCPRI, such employment is for no definite period of time and that UCPRI may terminate my employment at any time without previous notice and without cause - as the State of Rhode Island is an Employment at Will State.

I further understand that I may be required, as a condition of employment, to satisfactorily complete a medical examination and execute a confidentiality agreement.

I further understand that if employed by UCPRI, I must adhere to the rules and policies of the agency.