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We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Columbus House, Inc. (CHI) only accepts applications for open posted or advertised positions.

Type of employment desired:
Are you able to speak, read and/or write Spanish?:
Do you have any objection to working overtime if necessary?:
Can you travel if required by this position?:
Do you have a valid driver’s license (if required by position)?:
Have you ever been previously employed by Columbus House, Inc.?:
Have you ever received services from Columbus House or its affiliates?:
Are you related by blood or marriage to any CHI employee(s)?:
Are you legally authorized to work in the U.S. and accept new employment at Columbus House, Inc. in the position for which you are applying?:
Do you now, or will you in the future, require immigration sponsorship from Columbus House, Inc. in order to obtain, extend, or renew authorization to work in the U.S. in the position for which you are applying?:

Employment History

Please provide all employment information for your past four employers starting with the most recent.
Dates employed:
Type of employment:
May we contact this employer?:
Dates employed:
Type of employment:
May we contact this employer?:
Dates employed:
Type of employment:
May we contact this employer?:
Dates employed:
Type of employment:
May we contact this employer?:

Other Skills and Qualifications

Educational History

List school name and location, years completed, course of study, and any degrees earned:

Additional References

Please provide additional references if less than three listed under Employment History section. Do not include relatives.

Additional Reference 1:
Additional Reference 2:
Additional Reference 3:

Release and Authorization

I hereby authorize Columbus House, Inc. (CHI) to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability CHI and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that my employment is at-will and there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to complete Form I-9 for Employment Eligibility Verification and provide satisfactory proof of identity and legal work authorization on or before the date of hire. Failure to complete Form I-9 and submit such proof within the required time shall result in immediate termination of employment. I acknowledge that Columbus House Inc. will conduct a criminal background check and that I will be required to undergo substance abuse screening at Columbus House’s expense. (A conviction record will not necessarily be a bar to employment. Factors such as how long ago the offense was committed, seriousness and nature of the violation, and rehabilitation will be taken into account. In addition, you are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased under Connecticut law. Criminal records subject to erasure under Connecticut law are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty, or a conviction for which the person received absolute pardon. Any person whose criminal records have been erased under Connecticut law shall be deemed never to have been arrested within the meaning of the Connecticut General Statutes with respect to the proceedings so erased and may so swear under oath.) I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions. I hereby acknowledge that if I am employed my hours and/or shift may be altered at the sole discretion of Columbus House, Inc. and I agree to abide by all of the rules and policies of Columbus House, Inc. or be subject to termination.


We are gathering the following information not for employment decisions but for record keeping in compliance with Federal regulations. This information will be kept separate from your employment application. Your response is strictly voluntary and will help in developing and monitoring our affirmative action program.

Information provided will be kept confidential except that government officials investigating compliance will be informed. If you choose not to answer any questions, you will not be subject to adverse treatment.

Ethnicity: Are you Hispanic or Latino?
Race: If you answered “No” to the above question, please select one of the following:

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i 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
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression

  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)
Please check one of the boxes below:

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.

1Section 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’s Office of Federal Contract Compliance Programs (OFCCP) website at

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. This survey should take about 5 minutes to complete.


Columbus House, Inc. is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

  • A “disabled veteran” is one of the following:
    • a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
    • a person who was discharged or released from active duty because of a service-connected disability.
  • A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
  • An “active duty wartime campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
  • An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.

Veteran Identification:

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

Columbus House, Inc. is an equal opportunity employer with an affirmative action plan. Pursuant to Section 4212 of the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, it takes affirmative action to employ and advance in employment qualified veterans. (continued on next page)

Protected veterans may have additional rights under USERRA – the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free at: 1-866-4-USA-DOL.

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