Berkshire County Arc
395 South Street, Pittsfield MA 01201
APPLICATION OF EMPLOYMENT
BCARC Logo

It is the policy of BCArc to provide employment, training, compensation, promotion and other conditions of employment based on qualifications, without regard to race, religion, national origin, genetic information, sex, sexual preference, age, veteran status, Vietnam Era Veteran or being a member of the Reserves or National Guard, or disability. It is unlawful in MA to require or administer a lie detector test as a condition of employment or continued employment. Any employer who violates this law shall be subject to criminal penalties and civil liability.
* required fields
Date: 12/10/2018

REQUIRED – PLEASE READ

Requirements for any employment at Berkshire County Arc are: You must pass a CORI check, a SORI check, a Motor Vehicle Records check and a National Fingerprint Background check; possess a valid U.S. driver’s license and have a vehicle. (Relief positions do not require a vehicle.)
Applicant must Initial*

Position(s) Applied For*
Referral Source* Additional Info:

If you selected "Employee Referral", "Job Fair", or "Other" you must fill out this field.
 
Employee Name

Name:
                    Last Name*         First Name*      Middle Name
       
Address:
                      Street* Po Box/Other
       
Address:
                      City* State* Zip*
       
Telephone*:
  (With Area Code)  
       
Cell Phone: Email:*
  (With Area Code)    
Are you under 18?* YesNo
     If under 18, can you furnish a work permit?YesNo
Have you ever applied here before:* YesNo
     If yes, when:
     If yes, what program:
Have you ever been employed here before:* YesNo
     If yes, give date(s):
Are you employed now?* YesNo
May we contact your present employer?* YesNo

MANDATORY REQUIREMENTS FOR EMPLOYMENT
Please complete the following questions:

Are you proficient in reading and writing English?* Yes No
Do you possess a valid U.S. drivers license?* Yes No
Will you have a personal insured vehicle available to you (on site) (n/a for Relief Staff)?* Yes No
Do you possess a High School Diploma or equivalent?* Yes No
Are you lawfully authorized to work in the United States?* Yes No

On what date would you be available for work?

Please check all the shifts you could potentially work:(select at least one)*
Day
 
Weekends
 
Evening Overnight
 
         
Please check all the types of positions you would potentially be interested in:(select at least one)*
Full Time      Part Time Relief/Per Diem Summer
(40 hours)           

Employment Experience
Please list all employment, starting with present or most recent employer. Include relevant voluntary and/or part-time work experience.
Employer One
Employer Name
 
Job Title
 
Employer Address
 
Supervisor Name and Title
 
Supervisor E-mail
 
Supervisor Phone w/area code
Dates Employed
From
(month/year)
To
(month/year)
 
Work Performed
 
 
Reason for Leaving
 
May we Contact? YesNo

If no, may we contact pending employment offer? YesNo

Employer Two

Employer Name
 
Job Title
 
Employer Address
 
Supervisor Name and Title
 
Supervisor E-mail
 
Supervisor Phone w/area code
Dates Employed
From
(month/year)
To
(month/year)
 
Work Performed
 
 
Reason for Leaving
 
May we Contact? YesNo

If no, may we contact pending employment offer? YesNo

Employer Three

Employer Name
 
Job Title
 
Employer Address
 
Supervisor Name and Title
 
Supervisor E-mail
 
Supervisor Phone w/area code
Dates Employed
From
(month/year)
To
(month/year)
 
Work Performed
 
 
Reason for Leaving
 
May we Contact? YesNo

If no, may we contact pending employment offer? YesNo

Do you have a relative/family member/signifigant other currently employed at Berkshire County Arc?*
YesNo

If you answered Yes, please list the name of the person and the program they work in:
First Name Last Name BCArc Program Name
ADDITIONAL REFERENCES
*Give name, email address and telephone number of three references (i.e. previous employers, former supervisor, community service, professor, teacher, religious leader, etc.)
Do not list former co-worker/colleague, family or friends.

1.
    Name* Phone* Email* Connection*
 
2.
    Name Phone Email Connection
 
3.
    Name Phone Email Connection

LANGUAGES
Indicate what foreign languages you speak, read and/or write, if any.
SPEAK 1. 2.
  READ 1. 2.
 WRITE 1. 2.

Special Skills and Qualifications
Summarize special skills and qualifications acquired from employment or other experience. i.e. CPR, FA, CNA, EMT, MAP etc.

EDUCATION HISTORY
  Name City/State Course/Degree Graduated # Of Years Attended
High School*       Yes
      No
           
College       Yes
      No
           
Graduate School       Yes
      No
           

Applicant Data Record


Date*
   
Position(s) Applied For:
   
Name:
                    Last Name*         First Name*      Middle Name
       
Phone*:
  (With Area Code)  
       
Address:  
                      Street*
Address:
                      City* State* Zip*
       

Applicants are considered for all positions, and employees are treated during employment without regard to race, creed, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital or veteran status, or being a member of the Reserves or National Guard.

As employers/government contractors, we also comply with government regulations including but not limited to affirmative action responsibilities as required under Executive Order 11246 and Executive Order 13672.

Solely to help us comply with government record keeping, reporting and other legal obligations as required under these and other laws and regulations, we ask that you please fill out this Applicant Data Record. This data is for analysis and affirmative action only.

Submission of this information is voluntary. Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for employment. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.


Affirmative Action Data - Gender
   
Check One:
      Male
      Female
      I prefer not to disclose
Affirmative Action Data - Ethnicity/Race
Ethnicity:
Are you Hispanic or Latino?

No, I am not Hispanic or Latino.
Yes, I am Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
I prefer not to disclose

Race - IMPORTANT - Only complete this section if you checked "No, I am not Hispanic or Latino" in the Ethnicity section above:

What is your race? Select ONE of the following categories
White – A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
   
Black or African American – A person having origins in any of the Black racial groups of Africa.
   
American Indian/Alaskan Native – A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.
   
Asian – A person having origins in any of the original peoples 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.
   
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
   
Two or More Races – All persons who identify with more than one of the above five races.
I prefer not to disclose


Affirmative Action Data - Veteran

We are a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

  • A “disabled veteran” is one of the following:
    • a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
    • a person who was discharged or released from active duty because of a service-connected disability.
  • A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
  • An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
  • An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Veteran Status:
I identify as one or more of the classifications of protected veteran listed above
I am not a protected veteran
I am not a veteran
I prefer not to disclose

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

It is our policy to provide equal employment and advancement opportunities to all qualified individuals in all aspects of employment including but not limited to hiring, training, promotion, compensation, and all other personnel actions without regard to Disabled Veterans, Recently Separated Veterans, Active Wartime or Campaign Badge Veterans, or Armed Forces Service Medal Veterans or any other status that is protected by law. To achieve this goal, we are dedicated to taking affirmative action on behalf of Disabled Veterans, Recently Separated Veterans, Active Wartime or Campaign Badge Veterans, or Armed Forces Service Medal Veterans in compliance with Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA). Employees and applicants are protected from coercion, intimidation, interference or discrimination for:

  1. filing a complaint;
  2. assisting or participating in an investigation, compliance review, hearing or any other activity related to the administration of Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), or any other Federal, state or local law requiring equal opportunity for disabled persons, special disabled veterans or veterans of the Vietnam era;
  3. opposing any act or practice made unlawful by Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA) or its implementing regulations;
  4. exercising any other right protected by Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA) or its implementing regulations.
  5. Pursuant to this policy, a written affirmative action compliance program has been established which includes internal auditing and reporting systems to measure and evaluate the plan’s effectiveness. This program is available for review upon request by any applicant or employee during regular business hours.

    If you are an employee and a Disabled Veteran, Recently Separated Veteran, Active Wartime or Campaign Badge Veteran, or Armed Forces Service Medal Veteran that is covered by this program and would like to be considered under the affirmative action program, please tell us.


Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or
  • partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below

Disability Status:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON'T WISH TO ANSWER



Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2



Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.


APPLICANT/EMPLOYEE RELEASE AND PRIVACY STATEMENT
It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this agency/organization. I understand and agree that if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either my employer or myself. I also understand that this written agreement supersedes any and all oral representations made by agents or representatives of this agency/organization.
AGREEMENT: I certify that the information on this application is true, complete and correct. I thereby authorize the investigation of my past employment, education and activities and I release from all liability all persons, companies and corporations supplying such information. I understand that false answers, statements or significant omissions made by me on this form shall be sufficient cause for denials of employment or discharge.
Applicant must initial:*


*CLICK SUBMIT BUTTON TO ENTER APPLICATION WHEN FINISHED*
 
   
If you experience technical difficulties submitting your applications please contact Human Resources at (413) 499-4241 ext. 241 or 257