General Application

General Application

A Chance To Grow
Thank you for your interest in A Chance To Grow, Inc. (ACTG).
1. As part of our employment process, we require all applicants to complete this Employment Application. Please fill in the Employment History section even if you provide a resume. If a question is not applicable to you, please place an "N/A" in the space provided.
2. Please review the job description prior to answering the questions on the application.
3. ACTG is an Equal Opportunity Employer. Applicants are considered for positions without regard to race, religion, color, gender, gender identity, national origin, age, disability or handicap, marital status, sexual orientation, citizenship status, or status as a disabled veteran or veteran of the Vietnam era.
4. Federal law requires that all employers verify the identity and employment eligibility of all persons hired to work in the United States. ACTG uses E-verify to confirm work authorization. If the Government cannot confirm an employee hired by ACTG is authorized to work, this employer will provide the employee with written instructions and an opportunity to contact the SSA and/or DHS before taking adverse action, including termination.

Personal
Full Name:*

First NameMiddle NameLast Name
Present Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at this present address?*
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Have you lived in any other state in the past 5 years?

YesNo
If "yes", which state(s)?
From Mo/Yr to Mo/Yr:
Have you ever applied to, or worked for, A Chance To Grow, Inc.?*

YesNo
If "yes", please explain:

Position
Position applying for:*
If you are being directly hired by a client in the PCA Choice program, please provide the client's name:
Availability:*

Full-timePart-time
If "Part-time", what are the hours/days you are available?
If hired, what date would you be available to begin work? *

MonthDayYear
Salary Expectations:*
How did you hear about A Chance To Grow?*

Current EmployeeNewspaper AdACTG WebsiteOnline Job PostOther
If "Other", please explain:

Physical Data
After reviewing the job description for the position that you are applying for, can you perform the job with or without accommodations?*

With AccommodationsWithout Accommodations
If you answered "With Accommodations", please describe the accommodations needed:

Education
Highest level of education completed:*

High SchoolAssociateUndergraduateGraduateOther
If "Other", please explain:
School Name:
City, State:
Did you graduate?*

YesNo
What type of degree did you receive?*
Area of study:*
GPA:
Explain any additional schooling or specialized training not covered above:
Professional Certificates or Licenses (e.g. CPA, Nursing, Teaching etc.):

Employment History - 1
List your work history beginning with the present.Please include
1. All full-time jobs
2. All part-time jobs
3. All periods of self-employment
4. All periods of U.S. military service.
Employer:*
Phone Number:*
Please enter a valid phone number.
Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title and Responsibilities:*
Mo/Yr to Mo/Yr:*
Supervisor's Name and Title:*
Why did you (or do you want to) leave?*

Employment History - 2
Employer:
Phone Number:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title and Responsibilities:
Mo/Yr to Mo/Yr:
Supervisor's Name and Title:
Why did you (or do you want to) leave?

Employment History - 3
Would you like to add an additional past employer?*

YesNo
Employer:
Phone Number:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title and Responsibilities:
Mo/Yr to Mo/Yr:
Supervisor's Name and Title:
Why did you (or do you want to) leave?

Employment History - 4
Would you like to add an additional past employer?*

YesNo
Employer:
Phone Number:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title and Responsibilities:
Mo/Yr to Mo/Yr:
Supervisor's Name and Title:
Why did you (or do you want to) leave?

General
Are you under any obligation (e.g. confidentiality or non-compete agreement) to a current employer which may restrict your ability to accept employment at A Chance To Grow, Inc.?*

YesNo
If "Yes", please explain:
Do you expect to retain a financial interest in any business, or employment in another position, that may conflict with your employment at A Chance To Grow, Inc.?*

YesNo
If "Yes", please explain:
If hired, can you furnish proof that you are legally entitled to work in the U.S.?*

YesNo
Are you 18 years of age or older?*

YesNo

Business References

List 3 people that you currently work with or have worked with in the past. At least 2 references should be prior supervisors.
Name:*

First NameLast Name
Title:*
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Reference #2
Name:*

First NameLast Name
Title:*
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Reference #3
Name:*

First NameLast Name
Title:*
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant - Please read and sign
I am applying for employment with A Chance To Grow. I certify that the information provided on this application and any accompanying materials is true and complete to the best of my knowledge. I understand that any falsification or omission of information will be sufficient grounds for denial of employment or for dismissal if discovered at a later date. I understand that employment is conditioned upon verification of the information contained herein.

I authorize a thorough investigation of my past employment activities, and agree to cooperate in such an investigation. I authorize the listed employers, schools, and business references to give A Chance To Grow (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have, personal or otherwise. I release from all liability or responsibility, and agree not to sue, all persons and companies requesting or supplying such information.

I authorize schools, credit bureaus and law enforcement agencies to supply
information concerning my background. I understand that if any information herein is not true, my employment may be terminated.
Signature:*

Clear
Date:*

MonthDayYear

Affirmative Action Program Applicant Information Form
A Chance To Grow is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program.

Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as handicapped, disabled veteran, veteran of the Vietnam era, or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. We actively encourage women and minorities to apply. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Please complete the information requested below. Thank you for your cooperation.

Gender:

MaleFemaleNon-binary
If Other, please fill in the blank
EEOC Race/Ethnic Identification Categories
Hispanic or Latino (All Races) - All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

American Indian or Alaskan Native - All persons having origins in any of the original peoples of North America and South America (including Central America), and who maintain tribal affiliation or community attachment.

Asian or Other Pacific Islander - All persons having origins in any of the original people of the Far East, Southeast Asia, or the Indian Subcontinent including for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam and all persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Black or African American (Not of Hispanic origin) - All persons having origins in any of the Black racial groups of Africa.

Caucasion - All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Individual with Disabilities
Defined as a person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s), (2) has a record of such impairment(s), or (3) is regarded as having such impairment(s). For purposes of this definition, an individual with disability(s) is substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).

Special Disabled Veteran
Defined as a veteran who is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability (I) rated
at 30% or more, or (ii) rated at 10 or 20% in the case of a veteran who has been determined under Section 1506 to have a serious employment disability, or a person who was discharged from active duty because of a service connected disability.

Veteran of the Vietnam Era
Defined as a veteran who (a) served on active duty in the Republic of Vietnam between February 28, 1961 and May 7, 1975, or (b) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released therefrom with other than a dishonorable discharge, or (c) was discharged or released from active duty for a service-connected disability if any part of his or her active duty was performed between August 5, 1964 and May 7, 1975.

Other Eligible Veteran
Defined as any veteran who served in a “war” declared by Congress, in a campaign or on an expedition for which a campaign badge, a service medal, or an expeditionary medal has been awarded.

Attachments
Please upload your resume, cover letter, and any additional materials you wish to include. Thank you for applying.

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Should be Empty:

General Application

Personal

Position

Physical Data

Education

Employment History - 1

Employment History - 2

Employment History - 3

Employment History - 4

General

Business References

Business Reference #2

Business Reference #3

Applicant - Please read and sign

Affirmative Action Program Applicant Information Form

General Applicant Information

EEOC Race/Ethnic Identification Categories

Attachments