DavidsonWorks Online Application

Please complete the following online application to apply for DavidsonWorks programs and services.  The form MUST be totally completed (all sections) to have your application considered.

  
     
 
APPLICATION
*required fields
This field will only be used if applying in person at DavidsonWorks
Intake Specialist
Your Contact Information
Last Name *
First Name*
 Middle Name
 Date
03/10/2010
Time
01:06 PM
Street Address*

 Home Phone*
 City *
State*
 Zip Code*
 Mobile Phone
E-mail Address

 Last 4 Numbers of Social Security Number
 
Demographic Information

Gender*

  Male   Female
Date of Birth*
Month
Date
Year

Are You Disabled?*

  Yes        No

In the last 10 years, have you been convicted of a crime other than a minor traffic offense? (Being convicted of a crime will not automatically exclude you from employment)*

Yes        No

If yes, please explain:

  
 
Work Authorization

Are you a United States Citizen?*

Yes        No

Are you authorized to work in the United States if you are not a Citizen? (Proof will be required)
Yes        No      Does Not Apply to Me
 
Veteran Status

Are you a veteran?*

Yes        No

If YES, you are a veteran, please complete the following:

Branch of Service
From (Month/Year)
Month
Year
To (Month/Year)
Month
Year
Rank at Discharge
Type of Discharge
If other than Honorable, please explain:
 
Benefits/Services Receiving

Are you receiving any of the following benefits or services?  Please mark as "YES" if you are.

Yes     No Food and Nutrition Services (Food Stamps / SNAP)*
Yes     No Unemployment Insurance (UI)*
Yes     No WFFA/TANF*
Yes     No SSI Income*
Yes     No Medicaid*
Yes     No Medicare*
Yes     No Veterans Benefits*
Yes     No Disability Benefits*
Yes     No Social Security*
 

Education

HIGH SCHOOL

High School Name

High School City and State

Dates of Attendance

FROM (Year)

TO (Year)

Did you graduate?

COLLEGE (Most Recent)

College Name

College City and State

Dates of Attendance

FROM (Year)

TO (Year)

Did you graduate?

Yes        No

Degree

COLLEGE (Next Most Recent)

College Name

College City and State

Dates of Attendance

FROM (Year)

TO (Year)

Did you graduate?

Yes        No

Degree

Professional Certifications (list all that you have earned along with year earned, separated by a comma - for example: CISCO Certified 2007, Microsoft Certified 2006)

  

Other Training

1) Training School Name

Training City and State

Dates of Attendance

FROM (Year)

TO (Year)

Did you graduate?

Yes        No

Degree or Certification

Additional Other Training

2) Training School Name

Training City and State

Dates of Attendance

FROM (Year)

TO (Year)

Did you graduate?

Yes        No

Degree or Certification
     
 
EMPLOYMENT HISTORY
Complete this information starting with your most recent employer
 
1) Company Name
 Telephone

Address

City State Zip Code
Employment Period (Month/Year)
FROM:
TO:
Name of Supervisor

Ending Salary/Pay

Pay Amount Type
Job Title
Describe Work Performed

Reason for Leaving

May we contact Employer?
Yes        No

 
2) Company Name
 Telephone

Address

City State Zip Code

 

Employment Period (Month/Year)
FROM:
TO:
Name of Supervisor
 Ending Salary/Pay

Pay Amount Type
Job Title
Describe Work Performed

Reason for Leaving

May we contact Employer?
Yes        No

 
3) Company Name
 Telephone

Address

City State Zip Code

 

Employment Period (Month/Year)
FROM:
TO:
Name of Supervisor
 Ending Salary/Pay

Pay Amount Type
Job Title
Describe Work Performed

Reason for Leaving

May we contact Employer?
Yes        No

 
Services Inquiry
Please mark as "YES" all the DavidsonWorks Services you are interested in
Yes     No Career Guidance*
Yes     No Education*
Yes     No Training*
Yes     No Resume Help*
Yes     No Job Search Assistance*
Yes     No Child Care*
Yes     No Transportation*
Yes     No Food Stamps*
Yes     No Scholarships*
Yes     No Unemployment Benefits*
Yes     No Vocational Rehabilitation*
 

Type of Work Desired

Miles you are willing to commute to work

Date Available to start work
(MM/DD/YYYY)

Training Interest

Yes     No      Not Sure

Training Interest Categories
 
Referrals

1) Job Number

 Job Title

Referral Date

2) Job Number

 Job Title

Referral Date

3) Job Number

 Job Title

Referral Date
 

How did you learn about DavidsonWorks (check all that apply)?

TV Ad
Radio Ad
Friends/Family		 School Counselor
Internet Search
Career Fair		 Agency Referral
Direct Mail
Public Library		 Access Points
Community College
Other
       
You Must Check the Box Before Each RELEASE ITEM Statement Below to be Considered for Services or Employment Referral

RELEASE ITEM 1 - DavidsonWorks Authorization*

I authorize the DavidsonWorks JobLink System to disclose and/or verify the information needed for employment, training, JobLink services, and reporting purposes. It is understood that this information shall become a permanent part of my JobLink file. If a student, I authorize the disclosure of training, transcript and credential information to participating employers and the DavidsonWorks JobLink System. I also grant permission to survey my employer(s) regarding the quality of my performance.

 

RELEASE ITEM 2 - Information Verification*

I certify that the information provided in this application is true to the best of my knowledge. I am aware that this information will be verified and that any falsification shall be grounds to deny services and may be subject to prosecution under the law. I understand that the information will be used to determine eligibility for Workforce Investment Act (WIA) services and may be released for verification and federal reporting purposes.
 

RELEASE ITEM 3 - Reference Checking*

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give DavidsonWorks permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release DavidsonWorks from any liability as a result of such contact.
 

RELEASE ITEM 4 - Pre-Employment Drug Testing, and Drug and Alcohol Policy*

I also understand that (1) a potential employer may have a drug and alcohol policy that provides for pre-employment testing; and (2) consent to and compliance with such policy is a condition of my employment.
 
Thank you for completing this application.
       

 

 
 

 

   
 

An Equal Employment Opportunity Employer/Program.
Auxiliary aids and services are available upon request to individuals with disabilities.
Funded by the Workforce Investment Act.

Copyright DavidsonWorks, Inc., 2009.

 

 

 

 

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