Employment Application

Position applying for(Required)

Service Coordinator

Team Assistant

Service Coordinator (Intake)

Select position(s) you are applying for.

Are you 18 years of age or older?(Required)

Yes

No

You must be 18 years of age or older in order to apply for employment.

If hired, can you provide proof of identity and authorization to work in the U.S.?(Required)

Yes

No

You must be able to provide proof of identity/authorization to work in the United States.

Applicant Information

Full Name(Required)

First Last

Contact Phone Number(Required)

Ten digit phone number, i.e. 123-456-7890

Email Address

example@domain.com

Street Address(Required)

Street Address Address Line 2 City State ZIP Code

Interested in(Required)

Full-Time

Part-Time

Indicating interest does not guarantee selected work schedule.

Desired Work Population(Required)

Infants & Toddlers

Children & Youth

Adults

Administration

Other

Select all areas of interest.

Other(Required)

Are you able to perform the essential functions of this job, with or without reasonable accommodation?(Required)

Yes

No

For positions that require driving:

Do you have access to reliable transportation?

Yes

No

Do you have an acceptable driving record?

Yes

No

List any language(s) you speak, read, and write fluently other than English:

Were you referred by a Harbor Regional Center employee?

Yes

No

Name of Harbor Employee(Required)

First Last

Are you related to any Harbor Regional Center employee?(Required)

Yes

No

Name of Harbor Employee You Are Related to(Required)

First Last

Relationship to Employee(Required)

Education Information

High School Education

Name of High School(Required)

I have a(Required)

High School Diploma

Certificate of Completion

General Education Development (GED) Certificate

College Education

Name of College/University

Degree Obtained

Graduate/Professional

Name of Graduate/Professional Program

Degree/License Obtained

Other Professional Licenses/Certificates Held?

Please list other skills or training, including computer software programs you are proficient in

References

1. Name of Reference(Required)

First Last

Job Title(Required)

Company/Organization(Required)

Phone Number(Required)

E-mail Address

Is this reference a current and/or former supervisor?(Required)

Yes

No

2. Name of Reference(Required)

First Last

Job Title(Required)

Company/Organization(Required)

Phone Number(Required)

E-mail Address

3. Name of Reference

First Last

Job Title

Company/Organization

Phone Number

E-mail Address

Please upload resume(Required)

Max. file size: 100 MB.

Please upload cover letter

Max. file size: 100 MB.

Please upload completed Request for Additional Information Form(Required)

Max. file size: 5 MB.

The Request for Additional Information Form can be found under “Applicant Details.” Please complete the form in it’s entirety, sign and date it prior to uploading to this application. The max file size is 5MB.

Please upload completed Disclosure and Authorization Form(Required)

Max. file size: 5 MB.

The Disclosure and Authorization Form can be found under “Applicant Details.” Please complete the form in it’s entirety, sign and date it prior to uploading to this application. The max file size is 5MB.

Authorization of Application & Terms of Agreement

Please read the below carefully:

Authorization of Application & Terms of Agreement

I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for disqualification of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize HRC to thoroughly investigate my background, references, work record, education, and other matters related to my suitability for employment, and, further, authorize the references I have listed to disclose to HRC any and all information related to my work records. I agree to furnish information on my driving record and/or credit history or to allow HRC to collect such information if required for the position for which I am applying.

I understand that nothing contained in the application or conveyed during any interview or during my employment, if hired, is intended to create an employment contract between me and HRC. I understand and agree that if I am employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, at the option of either myself or HRC, and that no promises or representations to the contrary are binding on HRC unless made in writing and signed by me and HRC’s designated representative.

Terms of Agreement(Required)

I have read and agree with the Authorization of Application and Terms of Agreement above.

Digital Signature

I understand that by entering my name below, I consider this my electronic signature for this authorization and submission.

Name(Required)

First Name Last Name

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