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Home > Careers > Employment Application

APPLICATION FOR EMPLOYMENT

Family Allergy and Asthma is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, national origin, color, sex, sexual orientation, gender identity, or expression, age or disability. All information provided is considered confidential.

*All fields are required to be completed.

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PERSONAL INFORMATION:
NAME:*
First Middle Last
Maiden (if applicable):
Preferred Pronouns: (She / He / They)
ADDRESS:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Email Address*
Position Applied For:*
Position-Type:*
Location Interested in Working:*
Desired Salary:*
Date Available:*
MM slash DD slash YYYY
How did you hear about us?*
Have you ever been employed by Family Allergy & Asthma?*
- Yes
- No
If yes, when?
Do you have any family members working for Family Allergy & Asthma?*
- Yes
- No
If so, who?
Are you at least 18 years of age?*
- Yes
- No
Are you legally eligible to work in the United States? (If hired, you will be required to produce proof of eligibility to work in the United States, in accordance with Immigration Reform Act and Control Act of 1986.)*
- Yes
- No
Have you ever been convicted of a felony?*
- Yes
- No
A positive response will not necessarily bar you from employment.
If yes, 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
Have you ever served in the U.S. Military services?*
- Yes
- No
If yes, what branch?
If yes, please describe duties:

References:
Please list three (3) references (not related to you):
Name*
Relationship*
Phone*
Email*
Name*
Relationship*
Phone*
Email*
Name*
Relationship*
Phone*
Email*
Upload Resume:
File
Max. file size: 5 MB.
Conditions of Application and Employment

By entering my name below, I understand that I am submitting an application for employment. I certify that the answers given on this application (and accompanying documents, if any) are true and complete to the best of my knowledge. I understand that false or misleading information in any of my answers or statements may result in my application being eliminated from further consideration. I further acknowledge that all job offers are contingent on the successful completion of Family Allergy & Asthma’s pre-employment process including, but not limited to, reference checks and a background check. Finally, I understand how my personal data will be used and give permission to use the personal data that I submit to the Family Allergy & Asthma recruitment database for the above purposes.
Name*
First Last
Date*
MM slash DD slash YYYY
Invitation to Self-Identify

Family Allergy & Asthma is committed to equality of opportunity for all staff and job applicants. We acknowledge the unique contribution that all individuals can make and we aim to create a working environment in which all individuals are able to make use of their skills, free from discrimination or harassment, and in which all decisions are based on merit. This form is intended to help us maintain equal opportunities best practice and identify barriers to workforce equality and diversity.

The information on this form will be used for monitoring purposes only and will not be used in any decision affecting you. The information you provide will remain anonymous and will be stored separate to any job application. You are not obliged to answer any of these questions but the more information you supply, the more effective our monitoring will be. All information supplied will be treated anonymously.
Gender:
- Male
- Female
- Decline to Answer
Ethnicity:
- American Indian or Alaska Native
- Asian
- Black or African America
- Hispanic or Latino
- Native Hawaiian or Pacific Islander
- Two or More Races
- White
- Decline to Self-Identify
Veteran Status
- I am a Protected Veteran
- I am not a Protected Veteran
- I prefer not to disclose at this time.
Voluntary Self-Identification of Disability

Form CC-305 - OMB Control Number 1250-0005

Expires 1/31/2020

Why are you being asked to complete this form?

For government reporting purposes, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to: Blindness, Autism, Bipolar disorder, Post-traumatic stress disorder (PTSD) , Deafness , Cerebral palsy, Major depression , Obsessive compulsive disorder , Cancer , HIV/AIDS , Multiple sclerosis (MS) , Impairments requiring the use of a wheelchair , Diabetes , Schizophrenia , Muscular dystrophy , Epilepsy , Missing limbs or partially missing limbs , Intellectual disability (previously called mental retardation).

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.
Please check an answer below:
- Yes, I have a disability and do not require reasonable accommodation.
- Yes, I have a disability and require reasonable accommodation.
- No, I do not have a disability.
- I decline to respond at this time.
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