Our Mission: The Arc Mercer is committed to securing for all people with developmental disabilities the opportunity to choose and realize their goals.

Online Application

Enter the information requested into the appropriate spaces on the form. Please answer all questions. Review the information you entered for accuracy.

PERSONAL INFORMATION

Name:

Last

First

Middle

SS #:

Present Address:

Street

City

State

Zip Code

How long at this address:

Previous Address:

Street

City

State

Zip Code

How long at this address:

Telephone Number:

Home

Work

Email Address:

Referal Source:

Arc Mercer Website

Internet

Arc Employee

 

Newspaper

Walk In

 

 

If other, please specify:

 

Give name of person, newspaper, organization, website, etc:

If related to anyone employed by The Arc/Mercer, please state name of employee and department:

Name

Department

EMPLOYMENT DESIRED

Line of work:

Residential

Recreation

Daycare

Vocational

Administration

 

Adult Training

Clerical

Accounting

Maintenance

Other

Position:

Date you can start:

Salary Desired (in USD):

Type of employment:

Part-time

Full-time

Any

 

Select days and shifts desired:

Select one 7am-3pm 3pm-11pm 11pm-9am Not Available
Monday


Select one 7am-3pm 3pm-11pm 11pm-9am Not Available
Tuesday


Select one 7am-3pm 3pm-11pm 11pm-9am Not Available
Wednesday

Select one 7am-3pm 3pm-11pm 11pm-9am Not Available
Thursday


Select one 7am-3pm 3pm-11pm 11pm-9am Not Available
Friday


Select one 7am-3pm 3pm-11pm 11pm-9am Not Available
Saturday

Select one 7am-3pm 3pm-11pm 11pm-9am Not Available
Sunday

Ever worked for the agency before?:

Yes

No

If yes, when:

Ever applied for the agency before?:

Yes

No

If yes, when:

EDUCATION

High School:

Name and Location

No. of Years Completed

Degree / Diploma

College:

Name and Location

No. of Years Completed

Degree / Diploma

Graduate School:

Name and Location

No. of Years Completed

Degree / Diploma

Technical or Business Training:

Name and Location

No. of Years Completed

Degree / Diploma

Licenses / Certification*:

Name and Location

No. of Years Completed

Degree / Diploma

* Verification of Diploma, Degree, Licenses and Certifications may be required.

GENERAL INFORMATION

Special skills or experiences that may be job-related (3000 charcters):

US Citizen:

Yes

No

If no, can you legally be employed in the United States:

Have you ever been convicted of an offense including a crime, a disorderly persons offense, a petty disorderly persons offense, or a motor vehicle violation involving alcohol consumption or drug use?:

Yes

No

If Yes, explain:

Have you ever been adjudged civilly or criminally liable for abuse of a developmentally disabled person receiving services

Yes

No

If Yes, explain:

Do you have a valid driver's license?

Yes

No

Driver's License #:

If yes, what state?

NJ

PA

If other, please specify:


Date of Expiration:

Have your driver's license ever been revoked or suspended?

Yes

No

If yes, explain:

Are you atleast 18 years of age?

Yes

No

EMPLOYMENT HISTORY

List below last four employers, starting with current or most recent employer first.

If currently employed, may we inquire of your present employer?

Yes

No

Employer #1:

Employer

Address

 

Employer's Telephone Number

Supervisor & Title

 

Job Title

Duties Performed

Salary

 

Date From

Date To

Reason for Leaving

Employer #2:

Employer

Address

 

Employer's Telephone Number

Supervisor & Title

 

Job Title

Duties Performed

Salary

 

Date From

Date To

Reason for Leaving

Employer #3:

Employer

Address

 

Employer's Telephone Number

Supervisor & Title

 

Job Title

Duties Performed

Salary

 

Date From

Date To

Reason for Leaving

Employer #4:

Employer

Address

 

Employer's Telephone Number

Supervisor & Title

 

Job Title

Duties Performed

Salary

 

Date From

Date To

Reason for Leaving

REFERENCES

Reference #1:

Name

Address

 

Phone Number

Relationship

Years Known

Reference #2:

Name

Address

 

Phone Number

Relationship

Years Known

Reference #3:

Name

Address

 

Phone Number

Relationship

Years Known

PLEASE READ AND ANSWER THE FOLLOWING (IN SENTENCE FORM):

Describe your career goals and why you choose to apply to our agency:

AUTHORIZATION:

Do you agree with the terms:

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause of dismissal. I understand and agree that employment with the ARC/MERCER, Inc. is "at will" and may be terminated by the ARC/MERCER, Inc. at any time with or without cause or notice for any reason or no reason at all.

 

  I agree.

ANTI-SPAM

Enter the characters:

 

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