Employment Application: WIC - Nutritionist Assistant/Peer Counselor

• Personal Information

  Hope Enterprises does not discriminate in hiring on the basis of race, color, religion, sex, national origin, age, disability, veteran status, or status in any other group protected by federal, state or local law. Hope is firmly committed to the policy of Equal Employment Opportunity and strives to ensure that no individual is denied uniform treatment in any employment practice.

  Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity within three days of being hired. Failure to submit such proof within three days shall result in immediate termination of employment.

  Personal Information

  • First Name:
  • Middle Name:
  • Last Name:
  • Address:
  • Address 2:
  • City:
  • State:
  • Zip Code:
  • Phone Number:
  • E-mail Address:
  • Referral Source:
    Advertisement Career Link OVR Friend
    Relative Job Fair Walk-In Other — please explain
  • Referral Other:
  • Social Security Number:
  • Are you 18 or older?: Yes No
  • In what school district do you reside?:
  • Are you on layoff and subject to recall?: Yes No
  • Do you have a valid, current driver's license?: Yes No
  • Are you authorized to work in the United States?: Yes No
  • Have you been convicted of a crime that has not been sealed, annulled or expunged, other than a summary offense?: Yes No
  • If yes, describe in full including date(s). Please note that a guilty plea is considered a conviction. In addition, conviction of a felony will bar employment in most positions due to regulatory requirements. If you are in doubt as to whether a guilty plea was for a summary offense, you should disclose the conviction. If the conviction is for a summary offense, it will not affect the decision to employ you. Conviction of a misdemeanor does not necessarily disqualify you from employment. If yes, describe in full including date(s).:

  Submit
• Self-Identification

  Self-Identification

  Invitation to Self-Identify

  • Sex:
    Male Female Choose not to specify
  • Race/Ethnicity:
    Asian – not Hispanic or Latino
    Black or African American – not Hispanic or Latino
    Hispanic or Latino
    American Indian/Alaskan Native
    Native Hawaiian or Other Pacific Islander – not Hispanic or Latino
    White - not Hispanic or Latino
    Two or More Races
    Choose not to specify
  • Have you served in the United States Military?:
    Yes No Choose not to specify

  
  

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  Veteran Status

  1. This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

  • A “disabled veteran” is one of the following:
    • A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
    • A person who was discharged or released from active duty because of a service-connected disability.
  • A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
  • An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
  • An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

  Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll- free, at 1-866-4-USA-DOL.

  2. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

  
  

  • I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
    
    I AM NOT A PROTECTED VETERAN
    
    I DON'T WISH TO ANSWER
    

  
  

  As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. I BELONG TO THE FOLLOWING CLASSIFICATIONS OF PROTECTED VETERANS (CHOOSE ALL THAT APPLY):

  • DISABLED VETERAN
    
    RECENTLY SEPARATED VETERAN
    
    ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN
    
    ARMED FORCES SERVICE MEDAL VETERAN
    
    

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    I am a protected veteran, but I choose not to self-identify the classifications to which I belong.
    
    I am NOT a protected veteran.
    
    I DON'T WISH TO ANSWER
    

  
  

  If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.

  3. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

  4. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

  
  

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  Voluntary Self-Identification of Disability

  Why are you being asked to complete this form?

  We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified peoplewith disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individualswith disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.

  Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

  How do you know you have a disability?

  You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

  Disabilities include, but are not limited to:

  • Autism
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
  • Blind or low vision
  • Cancer
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or hard of hearing
  • Depression or anxiety
  • Diabetes
  • Epilepsy
  • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
  • Intellectual disability
  • Missing limbs or partially missing limbs
  • Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
  • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

  Please check one of the boxes below:

  • Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
    
    No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
    
    I Don’t Wish To Answer
    

  
  

  Reasonable Accommodation Notice

  Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

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  Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
  
  PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
• Desired Employment

  Desired Employment

  • Date you can start:
  • Are you available to work: Full Time Part Time Evenings & Weekends Third Shift
  • Shift Preference:  Days  Evenings  Overnights
  • Did you file an application here before?: Yes No
  • When did you apply?:
  • Have you ever worked for Hope before?: Yes No
  • Dates of Employment with Hope:
• Education

  Education

  If your education or former employment was under a different name, please indicate this where applicable and provide the name in the following sections.

  • High School

  • Name (include location):
  • Years Completed:
  • Diploma or Type of Degree:
  • Describe Course of Study:

  • College/University

  • Name (include location):
  • Years Completed:
  • Diploma or Type of Degree:
  • Describe Course of Study:

  • Graduate/Professional

  • Name (include location):
  • Years Completed:
  • Diploma or Type of Degree:
  • Describe Course of Study:

  • Other

  • Describe any honors received or specialized training, internships, skills and extra-curricular activities that may be helpful to us in considering your application:
  • Are you a member of any job-related organizations, clubs or professional associations? (Please exclude memberships that would reveal a legally protected status.)
  • Do you have any computer-related experience?: Yes No
  • If yes, please list any software programs in which you are proficient:
    
  • Do you have any other experience, skills or qualifications (including volunteer activities) that you feel relate to the position for which you are applying?
• References

  References

  List 3 business/work references from previous employers that supervised you. Provide full and accurate addresses and contact information. If this is not applicable, list 3 educational or personal references who are not related to you.

  • Reference 1

  • Name:
  • Address:
  • Phone Number:
  • Years Known:

  • Reference 2

  • Name:
  • Address:
  • Phone Number:
  • Years Known:

  • Reference 3

  • Name:
  • Address:
  • Phone Number:
  • Years Known:
• Employment History

  Employment History

  Start with your present or last job.

  • Employer 1

  • Name:
  • Address:
  • Telephone:
  • Dates Employed:
  • To:
  • Job Title:
  • Work Performed:
  • Supervisor:
  • Starting Hourly Rate or Salary:
  • Final Hourly Rate or Salary:
  • Reason for Leaving:

  • Employer 2

  • Name:
  • Address:
  • Telephone:
  • Dates Employed:
  • To:
  • Job Title:
  • Work Performed:
  • Supervisor:
  • Starting Hourly Rate or Salary:
  • Final Hourly Rate or Salary:
  • Reason for Leaving:

  • Employer 3

  • Name:
  • Address:
  • Telephone:
  • Dates Employed:
  • To:
  • Job Title:
  • Work Performed:
  • Supervisor:
  • Starting Hourly Rate or Salary:
  • Final Hourly Rate or Salary:
  • Reason for Leaving:
  • May we contact these employers?: Yes No
  • Which employer do you not want to be contacted?:
  • If you believe that a former employer would give you an unsatisfactory recommendation, please explain:
    
  • Have you ever been suspended without pay, forced to resign or discharged by a former employer? Yes No
• Clerical Applicants

  Clerical Applicants

  • Typing Speed (WPM):
  • Dictation Speed (WPM):
  • List all office machines with which you have experience:
  • List any additional skills you have such as shorthand, transcription or computer software programs with which you have experience:
    
• Upload Resume

  Upload Resume

  Allowed Files: .doc, .docx, .pdf
• Applicant Agreement

  Applicant Agreement

  I certify that answers herein are true and complete to the best of my knowledge.

  I authorize you to make such investigations and inquiries of my personal and employment history and other related matters as may be necessary now or at any time in the future in arriving at an employment decision. I further authorize and request that my current and all former employers, educational institutions and those people I have listed as references furnish Hope Enterprises, Inc. with information about my employment record, including a statement of the reason for termination of my employment, work performance abilities, and other qualities pertinent to my qualifications for employment; hereby releasing them and Hope Enterprises, Inc. from all liability and responsibility arising from any information provided.

  If offered employment with Hope Enterprises, I agree to submit myself to a criminal background check and to an employment physical examination, at the agency’s expense and as required by licensing regulations, and to future employment physical examinations at the agency’s expense, which may be required due to regulatory requirements or as a condition of my continued employment.

  If Hope Enterprises employs me, I understand that false or misleading information given in this application or interview(s) will result in discharge whenever discovered.

  Further, I understand that I am expected to abide by all rules and regulations of Hope as provided in its Personnel Policies, and that my employment can be terminated, with or without cause, and with or without notice, at any time, at the option of either the agency or myself.

  If Hope Enterprises offers you employment, it will be contingent upon submitting a urine sample that will be tested for the presence of controlled substances. This will be done in conjunction with the employment physical and tuberculosis testing. This test is in accordance with Hope’s “Drug, Narcotics and Alcohol Free Work Place Policy,” a copy of which is available upon request.

  My electronic signature (entered below) certifies that I have read, understood, and fully accept all of the terms contained in this employment application: (Please enter your full legal name)

  * Accept Terms: I Accept The Terms of this Employment Application.

  Are you a ROBOT