Acadiana Brain Injury Center

Acadiana Brain Injury Center
a division of Seidl & Associates, Inc.
P.O. Box 23 / 105 Betsy Ross, Youngsville, LA 70592

APPLICATION for EMPLOYMENT

Acadiana Brain Injury Center (ABIC) is an equal opportunity employer. Applicants for employment are considered without regard for race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

(PLEASE PRINT)

last name ____________________	first name ____________________		middle name ________________
street address ________________________________________________________________________________
city ______________________________________		state: ________	zip code ____________________
primary phone # ___ ___ - ______	alternate phone # ___ ___ - ______		date of birth _________________
Social Security number _______ - ______ - ___________	Position(s) applied for _____________________________		date of application ____________________________
Contact person & phone # in case of emergency: _____________________________________________________
How did you learn about ABIC? [ ] advertisement [ ] friend [ ] walk-in [ ] employment agency [ ] relative [ ] other: _____________________________________

If you are under 18 years of age, can you provide required proof of your eligibility to work?
[ ] yes [ ] no [ ] NA

Have you ever filed an application with ABIC before?
[ ] yes [ ] no
If yes, give date: _______________

Have you been employed with ABIC in the past?
[ ] yes [ ] no
If yes, give date: _______________

Are you currently employed?
[ ] yes [ ] no

May ABIC contact your present employer?
[ ] yes [ ] no

Are you prevented from lawfully becoming employed because of Visa or Immigration Status?
[ ] yes [ ] no

Date that you would be available for work? __________________

Available to work:
[ ] Full Time [ ] Part Time [ ] Shift Work [ ] Temporary

Are you currently on A lay-off@ status and subject to recall?
[ ] yes [ ] no

Can you travel if a job requires it?
[ ] yes [ ] no

Have you ever been convicted of a felony
[ ] yes [ ] no
If yes, please explain:
_______________________________________________________________________
_______________________________________________________________________

Do you currently hold a valid drivers license
[ ] yes [ ] no

EDUCATION

	School Name Address	courses of study	years completed	diploma degree
Elementary School	_________________________ _________________________	____________________ ____________________	_____	_________
Middle School	_________________________ _________________________	____________________ ____________________	_____	_________
High School	_________________________ _________________________	____________________ ____________________	_____	_________
College	_________________________ _________________________	____________________ ____________________	_____	_________
Graduate School	_________________________ _________________________	____________________ ____________________	_____	_________
other (specify)	_________________________ _________________________	____________________ ____________________	_____	_________

Indicate any foreign languages you can speak, read and/or write

fluent

good

fair

Speak ____________________
____________________ __________________
__________________ _________________
_________________

Read
__________________
__________________ __________________
__________________ _________________
_________________

Write ______________________
______________________ __________________
__________________ _________________
_________________

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

____________________________________________________________________________
____________________________________________________________________________

Describe any job-related training received in the United States military.

____________________________________________________________________________
____________________________________________________________________________

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which include race, color, religion, gender, national origin, disabilities or other protected status.

Employer: _____________________________	Dates Employed:
Address: ______________________________	from: _______________________________
______________________________________	to: _________________________________
Telephone number(s)	Hourly Rate / Salary:
__________________________________	starting $: _________	final $: ___________
__________________________________	Work Performed: ________________________
Job Title: ______________________________	___________________________________________
Supervisor: ____________________________	___________________________________________
Reason for Leaving: _____________________	___________________________________________
__________________________________	initial if ABIC may contact this employer: _______

Employer: _____________________________	Dates Employed:
Address: ______________________________	from: _______________________________
______________________________________	to: _________________________________
Telephone number(s)	Hourly Rate / Salary:
__________________________________	starting $: _________	final $: ___________
__________________________________	Work Performed: ________________________
Job Title: ______________________________	___________________________________________
Supervisor: ____________________________	___________________________________________
Reason for Leaving: _____________________	___________________________________________
__________________________________	initial if ABIC may contact this employer: _______

Employer: _____________________________	Dates Employed:
Address: ______________________________	from: _______________________________
______________________________________	to: _________________________________
Telephone number(s)	Hourly Rate / Salary:
__________________________________	starting $: _________	final $: ___________
__________________________________	Work Performed: ________________________
Job Title: ______________________________	___________________________________________
Supervisor: ____________________________	___________________________________________
Reason for Leaving: _____________________	___________________________________________
__________________________________	initial if ABIC may contact this employer: _______

Employer: _____________________________	Dates Employed:
Address: ______________________________	from: _______________________________
______________________________________	to: _________________________________
Telephone number(s)	Hourly Rate / Salary:
__________________________________	starting $: _________	final $: ___________
__________________________________	Work Performed: ________________________
Job Title: ______________________________	___________________________________________
Supervisor: ____________________________	___________________________________________
Reason for Leaving: _____________________	___________________________________________
__________________________________	initial if ABIC may contact this employer: _______

Employer: _____________________________	Dates Employed:
Address: ______________________________	from: _______________________________
______________________________________	to: _________________________________
Telephone number(s)	Hourly Rate / Salary:
__________________________________	starting $: _________	final $: ___________
__________________________________	Work Performed: ________________________
Job Title: ______________________________	___________________________________________
Supervisor: ____________________________	___________________________________________
Reason for Leaving: _____________________	___________________________________________
__________________________________	initial if ABIC may contact this employer: _______

If you need additional space, please continue on a separate sheet of paper.

List professional, trade, business or civic activities and offices held.

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

You may exclude organizations which include race, color, religion, gender, national origin, disabilities or other protected status.

Additional Information

Other Qualifications:
summarize special job-related skills and qualifications acquired from employment or other experience

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Specialized Skills: check skills/equipment operated Production/Mobile
___ CRT	___ Fax Machinery	(list)	Other (list)
___ PC	___ Spread Sheet	_____________________	_____________________
___ Calculator	___ PBX System	_____________________	_____________________
___ Typewriter	___ Word Processor	_____________________	_____________________

State any additional information you feel may be helpful to us in considering your application

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Note to applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING, OR A DESCRIPTION OF THE ACTIVITIES INVOLVED IN SUCH A JOB OR OCCUPATION IS ATTACHED.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? ___ YES ___ NO

References:

please list at least three (work) references that we may contact:
(do not use family members)

name____________________________________	phone: ____________________
address _________________________________________________________________
name____________________________________	phone: ____________________
address _________________________________________________________________
name____________________________________	phone: ____________________
address _________________________________________________________________

Applicant's Statement

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

I authorize investigation of all statements contained in this application for employment as well as authorize the Employer to contact any references noted as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is on an A at will@ nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this A at will@ employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant:_____________________________________________________

date: ______________________

FOR USE BY ABIC ONLY

Arrange Interview ___ YES ___ NO

Remarks: __________________________________________________________________________
__________________________________________________________________________

References contacted:

name: _______________________________________ date: _____________
name: _______________________________________ date: _____________
name: _______________________________________ date: ____________

Remarks: __________________________________________________________________________
__________________________________________________________________________

Employed: ___ YES ___ NO

Date of Employment: ____________________

Job Title: ____________________

Hourly Rate/Salary ________________ Dept ____________

By: _____________________________________________________________

date:_____________

(name & title)

Notes regarding prospective employee qualifications, ability, related experience, health, character, emotional stability and social skills as related to the appropriate job description:

FOR USE BY ABIC ONLY

Position(s) Applied for is Open:

Positions Applied For: __________________________________________________________________________
__________________________________________________________________________

Note:
__________________________________________________________________________
__________________________________________________________________________

	fluent	good	fair
Speak	____________________ ____________________	__________________ __________________	_________________ _________________
Read	__________________ __________________	__________________ __________________	_________________ _________________
Write	______________________ ______________________	__________________ __________________	_________________ _________________