NTI Employment Application Scratch Sheet by vsb11259


									NTI Employment Application “Scratch Sheet”

How to Use This Scratch Sheet
1. This Scratch Sheet helps you gather the information you need to apply online for a
   job at NTI. You can either save the information in this document as you gather it, or
   you can print this document out and fill it in by hand.
2. After you complete the scratch sheet, return to the NTI website to fill out an online
   application using the information you’ve gathered.
3. NTI provides this document solely for your convenience. Don’t email it to us
   because we can’t process it. NTI can process only the form you fill out online.
4. Some documents that might help you fill this form out include
   • Contact information for your Vocational Rehabilitation (VR) counselor
   • Contact information for your two most recent former employers
   • Records of dates of attendance and areas of study in high school and college
   • Records of dates of military service
   • Information about your telephone and Internet services
5. You will need to provide NTI with a recent resume in either Microsoft Word or Text
   format while filling out the online application. We don’t provide a form for your
   resume. You must have a resume file on your computer in order to “attach it” to the
   online application, though.

1. You must fill in every data field on the application in order for NTI to process your
   application. If a question doesn’t pertain to you, type N/A in the field.

2. Instructions in red text or marked by the “stop sign” icon , indicate an area
   where you must enter data in a specific way. Take a moment to read these
   instructions carefully before continuing.
3. Use your mouse or the TAB key on your keyboard to move from field to field
4. Please be careful to follow these instructions so that NTI can process your
   application properly. Incomplete or incorrectly completed applications will not be
   processed. We cannot consider you for a job without a complete and correct
5. If you have applied to NTI within the last 24 months, DO NOT fill out another
   application. If you are interested in another job, send email expressing your interest
   to ntirecruiting@nti.org.

v 4.1 (Revised: 6/26/2005)
Date of Application
     Date of Application          (mm/dd/yy)

Personal Information
Provide your legal first and last names. We cannot accept nicknames or aliases.

     First Name
     Last Name
     State                        (2-letter abbreviation)
     ZIP Code                     (5 digits)
     Home Phone Number            (      )
     Home Fax Number              (      )
     Email Address

Job Code and Personal Profile
    NTI Code number for the job   (From the NTI website)
    you’re interested in
    Position Name
    Date Available for work       (mm/dd/yy)
                                  ¨ Full-time
    Type of Employment
                                  ¨ Part-time
                                  ¨ Temporary
    If applying for Part-time,    (e.g., 20 hours per week)
    Specify Hours Desired
    If applying for Temporary,
                                  (mm/dd/yy to mm/dd/yy)
    Specify Dates Desired
    Salary Desired                ($ per Hour)

v 4.1 (Revised: 6/26/2005)
    Are you 18 years old or        ¨ Yes
    older?                         ¨ No

    Do you have a legal right to   ¨ Yes
    work in the US?                ¨ No

Source of Referral to NTI
                                   ¨ VR Counselor
                                   ¨ Job Accommodation Network
                                   ¨ Independent Living Center
    How were you referred to
                                   ¨ Internet Search
                                   ¨ School/Training Program
                                   ¨ Print Media
                                   ¨ TV / Radio
    Name of the source who
    referred you
    VR State                       (2-letter abbreviation)
    VR Counselor’s Name
    VR Counselor’s Phone No.       (       )
    VR Counselor’s E-Mail
    Do you require any
    accommodation during the       ¨ Yes
    application and interview      ¨ No
                                               DO NOT use the Enter / Return key in
                                               this box. Enter text as a single paragraph.

    If yes, describe the
    accommodation you require.

v 4.1 (Revised: 6/26/2005)
Criminal Record
    Have you ever been
    convicted of an offense other
    than a minor traffic
                                      ¨ Yes
    Note: A prior conviction
                                      ¨ No
    does not automatically
    disqualify you from
    consideration for
                                              DO NOT use the Enter / Return key in
                                              this box. Enter text as a single paragraph.

    If yes, please provide an

Military Service

    Have you ever served in the       ¨ Yes
    U.S. Military?                    ¨ No
                                              DO NOT use the Enter / Return key in
                                              this box. Enter text as a single paragraph.
                                      US Army 1976-1980. US Army Reserve 1980-1982.
    If yes, please list your branch
    of service and the years
    during which you served

v 4.1 (Revised: 6/26/2005)
                                 ¨ No formal education level completed
                                 ¨ Elementary (Grades 1-8)
                                 ¨ Secondary education; No high school diploma
                                   (Grades 9-12)
                                 ¨ Special education certificate of completion or
    Check the highest level of     attendance
    education you completed      ¨ High school graduation or equivalent (GED)
                                 ¨ Post-secondary education, no degree
                                 ¨ Associate degree or Vocational technical
                                 ¨ Bachelor’s degree
                                 ¨ Master’s degree or higher
    High School
    High School Name
                                 ¨ Yes
    Did You Graduate?
                                 ¨ No
    Major / Subject
    College #1
    College Name
                                 ¨ Yes
    Did You Graduate?
                                 ¨ No
    Major / Subject


    College #2
    College Name
                                 ¨ Yes
    Did You Graduate?
                                 ¨ No
    Major / Subject


v 4.1 (Revised: 6/26/2005)
Related Skills and Qualifications
List information you believe will be helpful in considering you for employment such as
additional skills, qualifications, work experiences, volunteer work, awards, or
membership in professional associations.
Exclude any information that would divulge your race, color, religion, sexual
orientation, national origin, sex, age, disability, or veteran status.

                                  ¨ Yes
    Are you Bilingual?
                                  ¨ No
    If Yes, list languages
                                    ¨ Accounting
                                    ¨ Banking
                                    ¨ Bookkeeping
                                    ¨ Consulting
                                    ¨ Customer Service
                                    ¨ Data Entry
                                    ¨ Data Processing
                                    ¨ Dictation

    Select any of the boxes in this ¨ E-mail
    section indicating skills you   ¨ General Management
    possess that you would like     ¨ General Office
    NTI to consider in evaluating ¨ Insurance
    your application.               ¨ Medical Billing
                                    ¨ Medical Terminology
                                    ¨ Medical Transcription
                                    ¨ Microsoft Excel
                                    ¨ Microsoft PowerPoint
                                    ¨ Microsoft Word
                                    ¨ Payroll
                                    ¨ Sales
                                    ¨ WordPerfect

v 4.1 (Revised: 6/26/2005)
Most jobs require the ability to type. Indicate your approximate typing speed in words
per minute (WPM). If you’re unsure how fast you can type, take a free online typing test
at http://www.typingtest.com.
                                    ¨ 10 WPM
                                    ¨ 20 WPM
                                    ¨ 30 WPM
                                    ¨ 40 WPM
    Check the box closest to your   ¨ 50 WPM
    typing speed                    ¨ 60 WPM
                                    ¨ 70 WPM
                                    ¨ 80 WPM
                                    ¨ 90 WPM
                                    ¨ 100 WPM or higher

Previous Employers

    Employer #1
    Start Date                      (mm/dd/yy)
    End Date                        (mm/dd/yy)
    Employer’s Name
    Employer’s Phone Number         (    )
    Supervisor’s Name
                                             DO NOT use the Enter / Return key in
                                             this box. Enter text as a single paragraph.

    BRIEFLY List Your Job

    Reason for leaving

v 4.1 (Revised: 6/26/2005)
    Employer #2
    Start Date                    (mm/dd/yy)
    End Date                      (mm/dd/yy)
    Employer’s Name
    Employer’s Phone Number       (       )
    Supervisor’s Name
                                              DO NOT use the Enter / Return key in
                                              this box. Enter text as a single paragraph.

    BRIEFLY List Your Job

    Reason for leaving

    May we contact your current   ¨ Yes
    and/or previous employers?    ¨ No
                                              DO NOT use the Enter / Return key in
                                              this box. Enter text as a single paragraph.

    Explain why or why not

v 4.1 (Revised: 6/26/2005)
Internet / Telephone Company Information
Please answer these questions about your telephone and Internet services to the best of
your knowledge. Since most of the jobs we list are telecommuting positions, your phone
company and Internet access can be important considerations.
    Do you have Internet Access      ¨ Yes
    in your home?                    ¨ No
                                     ¨ Dial-Up
    Select the type of Internet      ¨ DSL
    access you currently have.       ¨ Cable
                                     ¨ Satellite
                                     ¨ AOL
                                     ¨ Comcast
                                     ¨ Compuserve
    If you have a broadband
    Internet Service Provider        ¨ Earthlink
    (ISP) for your DSL, satellite,   ¨ Verizon
    or cable connection, who is
    it?                              ¨ Other

                                     ¨ N/A
                                   ¨ AT&T Worldnet
                                   ¨ AOL
                                   ¨ Compuserve
                                   ¨ Earthlink
    If you have a dial-up Internet
                                   ¨ Juno
    Service Provider (ISP), who
    is it?                         ¨ NetZero

                                     ¨ Other

                                     ¨ N/A
    What Telephone Company
    Handles Your LOCAL Calls
    What Telephone Company
    handles your LONG
    DISTANCE phone calls?

v 4.1 (Revised: 6/26/2005)
Emergency Contact Information
    Contact Name
    Contact Phone                  (      )

Applicant Self Identification
At the conclusion of the application, we will ask you the following three questions
solely to help comply with government regulations and our affirmative action
responsibilities. We will keep your data confidential. If you answer the questions and
submit them as part of your application, you agree that your disclosure of the
information regarding sex, race, veteran or disability status is voluntary.

                                   ¨ Female
                                   ¨ Male
                                   ¨ American Indian or Alaskan Native
                                   ¨ Asian or Oriental
                                   ¨ Black or African American
    Race or Ethnic Group
                                   ¨ Hispanic
                                   ¨ Pacific Islander or Native Hawaiian
                                   ¨ White or Caucasian
                                   ¨ Disabled Veteran
                                   ¨ Vietnam Veteran
    Veteran Status
                                   ¨ Other Eligible Veteran
                                   ¨ Non-Veteran

Final Statement
When you submit your application, we will ask you to agree to the conditions described
in following statement. If you do not consent to these conditions, please do not submit
your application, since we will not process it without your consent.
Pressing the SUBMIT button acts as your “SIGNATURE” for your application, and
submits your voluntary information provided in the Employee Self Identification
section of the application.

v 4.1 (Revised: 6/26/2005)
                                  Applicant’s Statement

I authorize investigation of all the statements made and matters raised in the interview
process, including those contained in this application which NTI may deem relevant to
employment. I authorize all my previous employers or other persons having
information concerning me or my record to report such information to NTI. I release
each such person from all claims or liabilities whatsoever on account of making such
inquiries or making such disclosures, whether favorable or unfavorable.
I understand and agree that I shall be subject to immediate dismissal from employment
if NTI subsequently determines or discovers that the answers herein are untrue or that I
have failed to disclose a material fact. I understand and agree that any period of time
prior to the discovery or determination thereof shall not constitute a waiver or
abandonment or bar NTI’s right to take such disciplinary action.
If NTI requests, I agree to submit to a job-related physical examination at NTI’s expense
by a physician designated by NTI. I understand that in such case I must obtain medical
approval prior to commencing my employment.
I understand that nothing contained in the Application of Employment or in the
granting of an interview in any way implies that I will be employed. I understand that if
I am hired, my employment is not guaranteed for any length of time and that
employment and compensation can be terminated with or without cause, and with or
without notice, by me or NTI for any reason at any time.
EEO Statement: Applicants are considered for positions for which they are applying
without regard to race, color, sexual orientation, religion, the observation of religious
practices, political activity, ancestry, sex, creed, national origin, citizenship status, age,
marital or veteran status, or the presence of disability which would not prevent the
applicant from properly performing the job if given reasonable accommodation by the

v 4.1 (Revised: 6/26/2005)

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