Welcome to Peckham s Employment Services

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1 ) N. Black Canyon Highway Suite 200 Phoenix, AZ Welcome to Peckham s Employment Services Thank you for your interest in Peckham. We are a community rehabilitation organization, providing employment opportunities for people who have a documented disability or other identified vocational barrier. In order to qualify for employment and training programs at Peckham, program participants must have a significant disability and be unable to independently obtain and maintain employment in a competitive environment due to limitations in work skills, work tolerance, communication, mobility, and/or self-care as a result of a documented disability. Please pay special attention when completing the Eligibility for Services section of this application. Information you provide on these two pages will help determine if you are eligible for training and employment at Peckham. You will be asked to provide documentation of your disability from a qualified professional (physician, psychologist, or psychiatrist). We request that you bring this documentation to your interview, if possible. The Intake Specialist will describe additional program requirements during your interview. Due to the high volume of applications we receive, we are unable to call back every applicant. If, after reviewing your information, you appear to be eligible for Peckham services and you are selected to move forward in the hiring process, we will call you for an interview. 1

2 Service Application for Peckham Programs Name Street Address Telephone Number City, State, Zip Alternate Number What kind of position are you applying for? Call Center Have you ever been employed by Peckham? Yes No If yes, Location Dates of Employment Name employed under (If different now) Are you 18 years of age or older? Yes No If under 18, applicant will be required to submit a birth certificate or a work certificate as required by State or Federal laws. Can you, after employment, submit verification of your legal right to work in the United States? Yes Do you have a Social Security Administration Ticket to Work? Yes Employment Source: Former Employee Walk-in Flyer School / College Other US Military Branch of Service Date Discharged Agency Referral: Name of Agency Name of Counselor Date Entered Highest Rank Do you have service-related skills and/or experience applicable to civilian employment? Yes No If yes, describe No No General What additional relevant experiences or training have you had other than your work experience, military service and/or education? Activities - civic, athletic, fraternal, etc. (Exclude organizations which indicate race, religion, color or national origin of members.) Have you ever been convicted of a felony? Yes No Have you ever been convicted of any type of theft, fraud or a violent crime? Yes No Availability Do you prefer: Part-Time Full-Time Check if you are available to work: Saturday Sunday Shift Hours: Our National Passport Information Center hours of operation are 5:00am to 8:00pm - Monday through Friday. Are you available to work anytime between these hours? Yes No If No, what days and hours are you avialble to work? EEO An equal opportunity employer/program auxiliary aids and services are available upon request to individuals with disabilities

3 Employment Background List below your three most recent employers, beginning with the current or most recent (If you have had less than three employers use the remaining spaces for personal references). If you were employed under a maiden or other name, please enter that name in the right hand margin. May we contact your present employer? Yes No Most recent first: Company Name Address Job Title Name of Supervisor Phone Date Started Date Left Base Salary or Wage Company Name Address Job Title Name of Supervisor Phone Date Started Date Left Base Salary or Wage Company Name Address Job Title Name of Supervisor Phone Date Started Date Left Base Salary or Wage List 2 people (no relatives) you have worked with and whom we may contact for a reference if necessary. Name: Name: Occupation: Occupation: Phone Number: Phone Number: Street: Street: City, State, Zip: City, State, Zip: We are glad you are interested in joining Peckham. Please read the following statements carefully before you sign and return this application. The company, in considering my application for employment, may verify the information set forth on this application and obtain additional background information relating to my background. I authorize all persons, schools, companies, corporations, credit bureaus and law enforcement agencies to supply any information concerning my background. I have read, understand and agree to this statement (Please initial here) I certify that the information on this application is correct and I understand that any misrepresentation or omission of any information will result in my disqualification from consideration for employment or if employed, my dismissal. I have read, understand and agree to the statement above (Please initial here) I understand that this application is good for sixty (60) days from today s date. If I still desire a position with the company after this application expires, it will be my responsibility to fill out a new application and file it with the company. Date of Application Signature (As shown on Social Security card)

4 Release for Security Check I,, authorize Peckham, Inc., the State of, and/or the federal government to do a background security check for the purpose of employment at Peckham. These checks may be run annually or more frequently due to probable cause. Please Print *Full Name: (last, first, middle initial) *Driver s License Number or State of ID#: *Date of Birth: *Address: (City, State, Zip) *Fields marked must be filled out Signature of Applicant or Legal Guardian Date EEO An equal opportunity employer/program, auxiliary aids and services are available upon request to individuals with disabilities.

5 Eligibility for Services The information requested on this form will be used to assist in determining your qualifications for vocational programs at Peckham. All information will remain confidential. To be eligible for most programs at Peckham, it is necessary to provide a medical doctor or psychologist s documentation of a current medical, mental/emotional or substance abuse concern. If you have any questions regarding your eligibility for services at Peckham, please contact Elizabeth O'Rourke at Applicant s Name: Date: Please state your diagnosis: Please check all medical conditions for which you are currently receiving treatment: Cancer Carpal Tunnel Syndrome Degenerative Disc Disease Diabetes Emphysema Fibromyalgia Traumatic Brain Injury Impaired Mobility Kidney Disease Liver Disease Loss of Limb Obesity Seizure Disorder Severely Impaired Hearing Severely Impaired Vision Stroke Other: Please check all limitations which you are currently facing due to your medical condition(s): Standing Sitting Walking Lifting Fatigue/Weakness Difficulty Concentrating Impaired Memory Tolerance to Temperature Changes Tolerance to Environmental Changes (Gas, Fumes, Air Quality) Pain and/or Headaches Other:

6 Eligibility for Services, continued Please check any emotional or mental health concerns you may have: Are you currently being treated by a psychiatrist, mental health therapist, or counselor? Have you ever been told by a doctor or therapist that you were depressed, anxious, suicidal, bipolar or schizophrenic? Are you currently taking medication for depression or anxiety, such as: Zoloft, Paxil, Prozac, Celexa, Lexipro or Xanax, Ativan, Serax, Clozaril, Serentil, Lithium, Eskalith, Lithane, Tegretol or Depakote? Were you enrolled in special education classes while in school? If yes, please state the reason you received special education services: Have you ever been diagnosed with Adult Attention Deficit Disorder? Are you taking medication for ADD or ADHD, such as Ritalin, Strattera or Adderal? Are you currently receiving treatment for substance abuse? Yes No If you answered yes, is the treatment for: Alcohol abuse Other drug abuse Are you taking medication to treat substance abuse? Yes No Please list any other information you feel would be helpful in determining your eligibility for services:

7 Relatives or Close Relationships of Peckham, Inc. Applicant Disclosure It is not unusual in large companies for employees to be relatives of, or to have close relationships with, applicants who apply for positions in all areas of a company. We here at Peckham, Inc. have found that these situations may, at times, be troublesome for the new employee and also for the company. In addition to problems with perceived favoritism and claims of partiality in treatment, problems away from the work environment can be carried over into day-to-day working relationships. The criteria for employment at Peckham, Inc. of relatives and close relationships has always been to hire applicants that meet the job-related skills, qualifications, and in the opinion of Peckham, do not create a conflict of interest. We do not hire nor reject an applicant based upon relationship status. We do, however, take steps to assure placements are in appropriate departments and positions. You must disclose, in writing to Human Resources, if you have any relatives and/or close relationships with Peckham, Inc. employees before we make any job offer with our company. This disclosure must be submitted and approved by the Human Resource Department. Any job offers made without this approval are not valid. State the name and relationship of the person(s) you disclose as working at Peckham, Inc: Name: Relationship: No relationships to disclose: (check here) Applicant Signature: Date: Print your name:

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