IC Employment Form

Employment Application Form

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Position(s) you are applying for:*
Date of Application*
MM slash DD slash YYYY
Name
First Middle Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone*
Work Phone
Email Address*
Referral Source
If you are under 18 and it is required, can you furnish a work permit?*
- Yes
- No
If no, please explain*
Have you ever been employed here before?*
- Yes
- No
If yes, give dates and positions*
Are you legally eligible for employment in this country?*
- Yes
- No
Date available for work*
MM slash DD slash YYYY
Type of employment desired*
- FT
- PT
- PD / On Call
- Temp / Seasonal
Desired salary range*
Are you able to meet the attendance requirements of this position?*
- Yes
- No
Employment History
Starting with your most recent employer, assignments or volunteer activities, provide the following information.
Employer #1
Employer*
Employment Date From*
MM slash DD slash YYYY
Employment Date To*
MM slash DD slash YYYY
Employer Address*
Street Address City State ZIP Code
Employer Phone Number*
Starting Job Title*
Final Job Title*
Salary Starting*
Salary Final*
Immediate Supervisor Name*
May we contact them for reference?*
- Yes
- No
Job Responsibilities*
Reason for leaving*
Employer #2
Employer
Employment Date From
MM slash DD slash YYYY
Employment Date To
MM slash DD slash YYYY
Employer Address
Street Address City State ZIP Code
Employer Phone Number
Starting Job Title
Final Job Title
Salary Starting
Salary Final
Immediate Supervisor Name
May we contact them for reference?*
- Yes
- No
Job Responsibilities
Reason for leaving
Employer #3
Employer
Employment Date From
MM slash DD slash YYYY
Employment Date To
MM slash DD slash YYYY
Employer Address
Street Address City State ZIP Code
Employer Phone Number
Starting Job Title
Final Job Title
Salary Starting
Salary Final
Immediate Supervisor Name
May we contact them for reference?*
- Yes
- No
Job Responsibilities
Reason for leaving
Criminal History Check
NOTE TO APPLICANT: Due to the nature of certain positions at this company, a criminal background check may be necessary as part of our application process. If you are advised that this is necessary concerning the position you are applying for, please provide the information requested below, otherwise, you may skip this section.

*PLEASE NOTE WHEN ANSWERING THE FOLLOWING QUESTIONS:
(i) CT law prohibits employers from requiring disclosure of an arrest, criminal charge or conviction for which records have been erased.
(ii) Any person whose criminal records were erased will be considered to have never been arrested or convicted for such matter(s), and may swear so under oath concerning such erased records.
(iii) The type of criminal records subject to erasure are those pertaining to:
• a finding of delinquency or that a child was a member of a family with service needs;
• a sentence as a youthful offender;
• a criminal charge that was dismissed or nolled;
• a criminal charge for which the person was found not guilty; and
• a conviction for which the person received an absolute pardon.
Have you ever been convicted* of a felony?*
- Yes
- No
If you answered Yes above, please indicate below*
(i) the date(s) of the conviction(s)
(ii) describe the circumstances and nature of the offense, and
(iii) describe what rehabilitation you have been through concerning such conviction(s)
Consent*
I agree to the terms below.
I hereby give permission for the Company to conduct a criminal background check for any record of a felony conviction. A conviction
record will not necessarily be a bar to employment, but factors such as recency, rehabilitation, and relatedness to fitness to perform the job
in question will be considered. I agree to fully cooperate in any such background investigation, and to sign any waivers or releases that
may be necessary to obtain accessto relevant information. In the event that any custodian of data will not release reference information or
criminal history information directly to the Company, I agree to personally request such information to the extent permitted by law. I
understand that any conviction record(s) discovered during such investigation will be kept confidential and will not be disclosed to anyone
except those Company personnel representatives with a need to know based on management responsibilities or involvement with the
hiring process.
Signature*
Date*
MM slash DD slash YYYY
Educational Background
School #1
School & Location*
Course of Study/Major*
Years Completed*
Degree/Diploma*
School #2
School & Location
Course of Study/Major
Years Completed
Degree/Diploma
School #3
School & Location
Course of Study/Major
Years Completed
Degree/Diploma
School #4
School & Location
Course of Study/Major
Years Completed
Degree/Diploma
References - Do Not Include Relatives
Reference #1
Name*
First Last
Title*
Relationship to Candidate*
Phone*
Years Known*
Reference #2
Name*
First Last
Title*
Relationship to Candidate*
Phone*
Years Known*
Reference #3
Name*
First Last
Title*
Relationship to Candidate*
Phone*
Years Known*
Military Service
Branch of Service
Dates of Service
Type of Discharge
Rank & Type of Service
Training / Experience Received
Please list any additional information that relates to your ability to perform the job for which you have applied – such as licenses, professional memberships, specialized training etc.
Applicant’s Statement
Consent*
I agree to the terms below.
I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves that same right to terminate my employment at any time, with or without cause or prior notice, except as may be required by state or
federal law. This application is not an agreement or contract for employment. I understand that no supervisor or representative of the employer is authorized to make any assurances, implied, oral or written to the contrary and that all such statements are invalid unless written and signed by the employer’s Board of Directors.

I also understand that if I am hired, I will be required to provide proof of employment authorization and identity. Failure to submit such proof will result in denial of employment.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect will be sufficient cause to cancel further consideration of my application or immediately discharge me from employment whenever it is discovered.

Do not sign until you have read the above applicant statement.

I certify that I have read, fully understand and accept all the terms of the Applicant Statement. I also certify that all information that I have supplied is true and that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.
Signature*
Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

IC Employment Form

Employment Application Form

Employment History

Employer #1

Employer #2

Employer #3

Criminal History Check

Educational Background

School #1

School #2

School #3

School #4

References - Do Not Include Relatives

Reference #1

Reference #2

Reference #3

Military Service

Applicant’s Statement