1.Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, genetic information, marital or veteran status, or the presence of a non job related disability.

Date

Position Applied for

Date Available for Work

Last Name

First Name

Street Address

City

State

Zip Code

Primary Phone #

Alternate Phone #

Email Address

2.How did you find out about the open positions here at Ark Regional Services?

Website

Indeed

HireWYO

Family / Friend

Facebook

Other (please specify)

3.Relatives currently working for Ark Regional Services (Name, relation, and position).

4.Have you ever been employed by Ark Regional Services?

Yes

No

5.If yes, please answer the following:

Position

Dates of employment

Supervisors name and title

Reason for leaving

6.Are you available full time and/or part time?

Full time

Part time

7.Days and times you are available to work.

*8.Most of our jobs require driving a company car.

Are you at least nineteen (19) years of age?(Required.)

Yes

No

*9.Do you have a valid driver's license?(Required.)

Yes

No

*10.Have you had 3 or more moving violations, such as speeding, in the last 3 years?(Required.)

Yes

No

*11.In the past 5 years, have you had any of the following major violations:

• Speeding ticket of 20+ miles per hour over the limit
• Conviction for an alcohol and/or drug related driving offense (DUI)
• Failure to stop/report an accident or leaving the scene of an accident
• Suspended license
• Racing
• Reckless or Careless driving

(Required.)

Yes

No

*12.Have you been determined to be at fault for an accident 2 or more times in the past 3 years?(Required.)

Yes

No

*13.Wyoming law requires Ark to screen employees based on criminal convictions, and Ark may choose not to hire an applicant based on criminal convictions other than those excluded by Wyoming law, based on consideration of the circumstances of the conviction. A criminal conviction will not necessarily disqualify you from employment, but failure to include any criminal convictions in the space below will result in the immediate disqualification of you as a candidate or termination of your employment when a conviction is discovered. The existence of a record of convictions for criminal offenses is not considered an automatic bar to employment.

Have you been convicted of any felony or misdemeanor (including through a jury verdict, a guilty plea, or a “nolo contendere” or no-contest plea)?(Required.)

Yes

No

14.If yes:

Date of conviction

Describe circumstances

15.Do you have a High School Diploma or GED Certificate?

Yes

No

16.Last high school attended

17.Higher Education

College or Vocational School

Dates from and to

Major

Minor

Degree earned

College or Vocational School

Dates from and to

Major

Minor

Degree earned

18.List other job-related qualifications, trainings, and skills.

19.Work history: List jobs in reverse order starting with your present or last job. Ark Regional Services will do a complete background verification of your work and personal history including police records.

Employer / Company

Phone #

Address

City, State, Zip

Dates from and to

Hours per week

Supervisor

May we contact?

Phone #

Did you supervise?

If yes, # of employees supervised

Reason for leaving

General duties

Employer / Company

Phone #

Address

City, State, Zip

Dates from and to

Hours per week

Supervisor

May we contact

Phone #

Did you supervise

If yes, # of employees supervised

Reason for leaving

General duties

Employer / Company

Phone #

Address

City, State, Zip

Dates from and to

Hours per week

Supervisor

May we contact

Phone #

Did you supervise?

If yes, # of employees supervised

Reason for leaving

General duties

20.Personal References:
List three references who are not related to you, and are not previous employers. Providing this information means that you give Ark Regional Services permission to contact these references.

Name

Email address

Phone #

Name

Email address

Phone #

Name

Email address

Phone #

*21.APPLICANT’S ACKNOWLEDGEMENTS:
(This application shall be considered active for the job vacancy listed and for no more than 60 days. After that time, the applicant will be required to resubmit a completed application. THE APPLICANT UNDERSTANDS THAT NEITHER THIS DOCUMENT NOR ANY OFFER OF EMPLOYMENT FROM THIS EMPLOYER CONSTITUTES AN EMPLOYMENT CONTRACT.)

I certify that all information contained on this application is true and that I have provided complete responses to all requests for information on the application. I give Ark Regional Services and its authorized agents permission to verify and investigate any employment, license, criminal background, and personal reference information given in connection with this application. In the event that I am employed, I understand that any false or misleading information I knowingly provided on my application, during my interview or hiring process may result in discharge and/or legal action.

ACKNOWLEDGEMENT OF AT-WILL EMPLOYMENT: I UNDERSTAND THAT IF I AM HIRED BY ARK REGIONAL SERVICES, MY EMPLOYMENT, COMPENSATION AND/OR BENEFITS CAN BE TERMINATED WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT THE OPTION OF EITHER ARK REGIONAL SERVICES OR MYSELF. I ALSO UNDERSTAND THAT NO EMPLOYEE, MANAGER OR SUPERVISOR OF ARK REGIONAL SERVICES HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT OR MAKE ANY PROMISES FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OR TIME OR MAKE ANY STATEMENTS OR PROMISES CONTRARY TO THIS DISCLAIMER, UNLESS SUCH AGREEMENT IS IN WRITING AND SIGNED BY THE CHIEF EXECUTIVE OFFICER. I UNDERSTAND THAT, IF I AM HIRED, NO CONDUCT OR STATEMENT, VERBAL OR WRITTEN WHICH CONTRADICTS THIS DISCLAIMER CAN CONSTITUTE AN EXPRESS OR IMPLIED CONTRACT REGARDING MY EMPLOYMENT, AND I SHOULD NOT RELY ON ANY SUCH CONDUCT OR STATEMENTS.(Required.)

Name of Applicant

Date