Position Applied For

Location

Center

Application Date

How did you learn about us?

Have you ever been convicted of a felony?

No
Yes

If yes, provide a written explanation.

First Name

Middle Name

Last Name

Street Address

City

State

Zipcode

Home Phone

Business Phone

Message Phone

Email

Some positions require shift work. Indicate the shift(s) you are available

Date available for work

Salary Expected

Have you ever been employed by or volunteered for The Centers?

Yes
No

If yes, please elaborate

Have you ever applied at The Centers or any of our member organization before?

Yes
No

If yes, please elaborate

Are any of your relatives employed by The Centers?

Yes
No

If yes, please elaborate

Highschool

School Name

Location

Number of Years or Hours Completed

Diploma/Degree

Major/Minor Course of Study

College

School Name

Location

Number of Years or Hours Completed

Diploma/Degree

Major/Minor Course of Study

Postgraduate

School Name

Location

Number of Years or Hours Completed

Diploma/Degree

Major/Minor Course of Study

Other

School Name

Location

Number of Years or Hours Completed

Diploma/Degree

Major/Minor Course of Study

Has a federal or state office told you that you are guilty of child/elder/client abuse or neglect?

Yes
No

If yes, please elaborate

Are you currently under investigation for child/client/elder abuse or neglect?

Yes
No

If yes, please elaborate

Certificate or License: Is your license currently under review?

Yes
No

If yes, please elaborate

Has your license ever been suspended or revoked?

Yes
No

If yes, please elaborate

OCCUPATIONAL HISTORY (INCLUDE UNITED STATES MILITARY SERVICE)

LIST ALL POSITIONS HELD , STARTING WITH YOUR MOST RECENT, AND WORKING IN REVERSE CHRONOLOGICAL ORDER

Employer 1

EMPLOYER

STREET ADDRESS

CITY

STATE

ZIP CODE

TITLE OR POSITION

SUPERVISOR

PHONE

FROM

TO

SALARY

REASON FOR LEAVING

SUMMARY OF DUTIES

Employer 2

EMPLOYER

STREET ADDRESS

CITY

STATE

ZIP CODE

TITLE OR POSITION

SUPERVISOR

PHONE

FROM

TO

SALARY

REASON FOR LEAVING

SUMMARY OF DUTIES

Employer 3

EMPLOYER

STREET ADDRESS

CITY

STATE

ZIP CODE

TITLE OR POSITION

SUPERVISOR

PHONE

FROM

TO

SALARY

REASON FOR LEAVING

SUMMARY OF DUTIES

I authorize The Centers, or its agents to make inquiry of my employment history. Further, I authorize persons, schools, my current and previous employer(s) to provide information as may be requested by The Centers for the purpose of making an employment decision.

Yes
No

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that intentionally false statements could lead to my dismissal as an employee or rejection as an applicant. I understand that my completion and submission of this application authorizes First Access, LLC and all participating member organizations to share information about my application, work history, disciplinary actions, performance appraisal, and termination of employment while working for any or all of the participating member organizations. I understand that a physical examination and drug test will be required prior to employment and that a job offer is conditioned on the results of the tests. I understand I may be asked to submit to periodic drug screens in the future. I understand that my employment The Centers and/or any member organizations is further conditioned on the results of the tests. I further voluntarily agree to such tests. I understand that any employment relationship with The Centers and/or any member organizationsis of an “at will” nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of The Centers and/or employing member organization I understand that conviction of a crime may disqualify me from employment, that disqualification depends upon the relationship of the crime to the position for which I am applying, and this application is my consent for The Centers and/or the employing member organization to request a criminal record and child/adult or client abuse/neglect check following a job offer.

Yes
No

Employment Application Form

Highschool

College

Postgraduate

Other

OCCUPATIONAL HISTORY (INCLUDE UNITED STATES MILITARY SERVICE)

Employer 1

Employer 2

Employer 3