* Position(s) applied for:

* Date of application:

* Referral Source:

Walk-in Employee Advertisement School Job Fair CPL's Website Other

* Please name the source of the referral:

* May we contact you at work?:

Yes   No

If yes, list your work number:

Best time to call at work (AM/PM):

* Are you at least 18 years old:

Yes   No

* Have you submitted an application to CPL before:

Yes   No

If yes, give date(s) and position(s):

* Do any relatives or friends work at CPL:

Yes   No

If so, who?:

* Have you ever been employed by CPL before?:

Yes   No

If yes, give dates: From:

To:

* Are you legally eligible for employment in the United States?:

Yes   No

Date available for work:

What is your desired salary range or hourly rate of pay?:

* Per:

Year Hour

* Type of employment desired:

Full-Time Part-Time Per Diem Temporary

* Will you travel if the job requires it?:

Yes   No

* Will you work overtime if required:

Yes   No

If no, please explain:

* Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?  :

Yes No Need more information about the job's 'essential functions'

Driver's licence number required if driving is required for the job for which you are applying:

State:

* Have you ever been convicted of or pled guilty to a crime?:

Yes   No

If Yes, please provide date(s) and details:

Starting with your most recent employer, provide the following information.

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Starting Job Title/Final Job Title	Immediate Supervisor and Title (for most recent position held)	May we Contact for reference?
		Yes No
Summarize the type of work and job responsibilities	Why did you leave?

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Starting Job Title/Final Job Title	Immediate Supervisor and Title (for most recent position held)	May we Contact for reference?
		Yes No
Summarize the type of work and job responsibilities	Why did you leave?

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Starting Job Title/Final Job Title	Immediate Supervisor and Title (for most recent position held)	May we Contact for reference?
		Yes No
Summarize the type of work and job responsibilities	Why did you leave?

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Starting Job Title/Final Job Title	Immediate Supervisor and Title (for most recent position held)	May we Contact for reference?
		Yes No
Summarize the type of work and job responsibilities	Why did you leave?

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Starting Job Title/Final Job Title	Immediate Supervisor and Title (for most recent position held)	May we Contact for reference?
		Yes No
Summarize the type of work and job responsibilities	Why did you leave?

Skill	Experince?	Sofware Titles	Years
Word Processing	Yes   No
Spreadsheet	Yes   No
Presentation	Yes   No
E-mail	Yes   No
Other	Yes   No
Other	Yes   No
Other	Yes   No

Starting with your most recent school attended, provide the following information.

School(include City & State)	Years Completed	Completed Detail	GPA Class Rank	Major/Minor
		Diploma or GED Degree Certification Other
		Diploma or GED Degree Certification Other
		Diploma or GED Degree Certification Other

Name	Title	Relationship to You	Phone Number	Number of Years Known

List special accomplishments, publications, awards, etc. that are relevant to the position for which you are applying.:

Is there any other job-related information you want us to know about you?:

I certify that all information I have provided in order to apply for and secure work with The Cerebral Palsy League, Inc. (CPL) is true, complete and correct.

I expressly authorize, without reservation, CPL, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all the information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding CPL, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that CPL does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and CPL reserves the same right to terminate my employment at any time with or without cause, with or without prior notice, except as required by law. This application does not constitute and agreement or contract for employment for an specified period or definite duration. I understand that no supervisor or representative of CPL is authorized to make any assurances to the contrary and that no implied oral or written agreement contrary to the foregoing express language are valid unless they are in writing and signed by CPL's Executive Director.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete and I-9 Form in this regard. In addition to the satisfactory completion of substantial pre-employment procedures will be required.


DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all the terms of the foregoing Applicant Statement.

* Signature (type name):

* Date: