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Application for Employment
Napa Valley Support Services (NVSS) is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability, handicap or veteran status.
Position(s) of Interest
(Required)
Full-time/ Part-time
(Required)
Full-time
Part-time
Date
MM slash DD slash YYYY
Name
(Required)
First
Middle
Last
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Driver license number:
State of Issue:
Last 4 of SSN
(Required)
Are you 18 years old or older?
(Required)
Yes
No
Are you able to perform essential functions of the job?
(Required)
Yes
No
If you are unable to perform essential functions, please explain
Are you legally eligible for employment in the United States?
(Required)
(If offered employment, you will be required to provide documentation to verify your eligibility.)
Yes
No
Work History
List most recent employment history first.
Upload your resume
We only accept PDF files.
Accepted file types: pdf, Max. file size: 3 MB.
Employer:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Address:
Phone#:
Position:
Supervisor:
Reason for Leaving:
Employer 2:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Address:
Phone# :
Position:
Supervisor:
Reason for Leaving:
Employer 3:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Address:
Phone# :
Position:
Supervisor:
Reason for Leaving:
Education
High School:
Years Completed
1
2
3
4
Diploma
Yes
No
GED
Yes
No
College/Vocation School:
City, State:
Major(s):
Degree Earned:
Other Training
Professional Licenses
(Do NOT disclose any organizations that may reveal protected/ discriminatory information.)
Type of License:
State of Issuance:
Expiration Date:
Skills
Please list skills:
Have you ever been employed by Napa Valley Support Services in the past?
(Required)
Yes
No
Have you ever been discharged or asked to resign from a job?
(Required)
Yes
No
May we contact your current employer?
(Required)
Yes
No
Professional References
Name:
Phone# :
Professional Relationship:
Years Known:
Name:
Phone# :
Professional Relationship:
Years Known:
Name:
Phone# :
Professional Relationship:
Years Known:
Certification and Agreement
Consent
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Napa Valley Support Services to verify their accuracy and to obtain reference information on my work performance. I hereby release NVSS from any/all liability of any kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.
I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for immediate dismissal.
I understand that should an employment offer be extended to me and accepted, that I will fully adhere to the policies, rules and regulations of employment of Napa Valley Support Services. However, I further understand that the policies, rules, regulations or employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either NVSS or I may terminate my employment at any time with or without notice or cause.
I agree
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