CONNECT AND LEARN

5100 BUCKEYSTOWN PIKE, SUITE 285

FREDERICK, MD 21704
PHONE: 301-694-6422
FAX: 301-694-6426

Employment Application
APPLICANT INFORMATION
Last Name:

First:

M.I.

Street Address:

Date:

Apt. / Unit #:

City:

State:

Zip:

Phone:

E-mail Address:

Date Available:

Are you 18 years old or older?

______ Yes

______ No

Position Applied for:

Have you plead "guilty" or "no contest", or been charged with a crime?
If yes, please give dates and details:

Answering yes to these questions does not constitute an automatic rejection to employment. Date of the offense,
seriousness and nature of the violation, rehabilitation and position applied for will be considered.

EDUCATION
High School:
From

Address:
To

Did you
graduate?

College:
From

To

Did you
graduate?

Degree:

YES

NO

Degree:

Address:
To

Did you
graduate?

Other:
From

NO

Address:

Other:
From

YES

YES

NO

Degree:

Address:
To

Did you
graduate?

YES

NO

Degree:

Please Note: All experience must be documented in detail (including time frames and number of
hours worked per week) on the application and your resume. Please document all experience
acquired through paid work, volunteer work, and/or caring for a family member or friend with autism
or other developmental disabilities.

PREVIOUS EMPLOYMENT: BEGIN WITH MOST RECENT EMPLOYMENT

Company:

Phone:

Address:

Supervisor:

Job Title:

From:

To:

Number of Hours worked per week:

Paid: ______

Volunteer Work: ______

Family Member/Friend: ______

Responsibilities:

Reason for Leaving:

Company:

Phone:

Address:

Supervisor:

Job Title:

From:

To:

Number of Hours worked per week:

Paid: ______

Volunteer Work: ______

Family Member/Friend: ______

Responsibilities:

Reason for Leaving:

Company:

Phone:

Address:

Supervisor:

Job Title:

From:

Number of Hours worked per week:

Paid: ______

Volunteer Work: ______

Family Member/Friend: ______

Responsibilities:

Reason for Leaving:

REFERENCES
Please list three professional references.

Job Title:

Name:

Relationship:

Address:

Phone:

Name:

Relationship:

Address:

Phone:

Name:

Relationship:

Address:

Phone:

ADDITIONAL QUALIFICATIONS: PLEASE TELL US ABOUT ANY OTHER EDUCATION, TRAINING, SKILLS, OR
ACHEIVEMENTS THAT YOU FEEL SHOULD BE CONSIDERED.

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. If this application leads to
employment, I understand that false or misleading information in my application or interview may result in my
release. I further understand that I give Connect and Learn permission to contact my references.
Signature:

Date: