ATTACHMENT TO EMPLOYMENT APPLICATION

Transcription

1 ATTACHMENT TO EMPLOYMENT APPLICATION ATTACH COPIES OF THE FOLLOWING ITEMS TO THE COMPLETED APPLICATION: Criminal Record Check (Obtained at County Courthouse) Diploma of highest level of education (High School, GED, College) College Transcripts if Degree not a Human Service Degree OTHER DOCUMENTS NEEDED PRIOR TO BEGINNING WORK: NC Drivers License Social Security Card Car Insurance Policy (Must show expiration date & coverage limits) TB Skin Test (From your doctor or health department) First Aid and CPR Certification (Training available thru Le Chris) NCI or CPI (Non-violent crisis intervention) (Training available thru Le Chris) Health Statement (Residential Staff Only) Attachment for Application Page 1 of 1 Last Update:

2 APPLICATION FOR EMPLOYMENT Le Chris, Inc. et al is an Equal Opportunity Employer and fully subscribe to the principles of Equal Employment Opportunity. Applicants and/or employees are considered for hire, promotion and job status, without regard to race, color, religion, creed, sex, marital status, national origin, age, physical or mental disability. NAME: DATE OF APPLICATION: Last First Middle Maiden Name Street City State Zip Code County TELEPHONE NUMBER: HOW LONG AT CURRENT OTHER COUNTIES/STATES OF RESIDENCE IN THE PAST 5 YEARS: COUNTY / STATE DATES 1. GENERAL INFORMATION: Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation(s)? Yes No If no, please explain (use additional sheet(s) if necessary): 2. EDUCATION & TRAINING: LIST HIGHEST GRADE COMPLETED FOR EACH: High School: College: Masters: Doctorate: LAST HIGH SCHOOL ATTENDED/ NAME & ADDRESS OF SCHOOL MAJOR COURSE STUDIED GRADUATED (Y OR N) OR DEGREE COLLEGE OR UNIVERSITY/ COLLEGE OR UNIVERSITY/ADDRESS OTHER SCHOOL (TECHNICAL, VOCATIONAL, GRADUATE, ETC.) / LIST ANY SCHOLARSHIPS, ACADEMIC HONORS, AWARDS OR SPECIAL ACHIEVEMENTS: 3. SKILLS PLEASE LIST ANY, CERTIFICATIONS, LICENSES, SKILLS YOU HAVE APPROPRIATE FOR THE YOU ARE APPLYING FOR: IF REQUIRED, WILL YOU WORK? ROTATING SHIFTS: YES NO SATURDAYS: YES NO OVERTIME: YES NO SUNDAYS: YES NO APPLYING FOR (BE SPECIFIC): DATE YOU COULD START: REQUIREMENTS: $ PER HOUR PER YEAR Application for Employment Page 1 of 4 Last Update:

3 APPLICATION FOR EMPLOYMENT EMPLOYMENT HISTORY starting with your PRESENT or MOST RECENT EMPLOYER list in consecutive order ALL EMPLOYMENT for at least the past FOUR employers. If currently employed, may we contact your employer Yes No FROM TO LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE AT THIS : LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE AT THIS : LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE AT THIS : LIST JOBS HELD, DUTIES PERFORMED, SKILLS USED, & PROMOTIONS WHILE AT THIS : READ CAREFULLY: I certify that the information contained in this application is correct to the best of my knowledge and understand that any misstatement or omission of information may result in denial of employment or discharge. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. Applicant Signature: Date: Signature of Interviewer: Date: Application for Employment Page 2 of 4 Last Update:

4 APPLICATION FOR EMPLOYMENT - QUESTIONNAIRE NAME: DATE: Please answer the following questions: 1. Why are you interested in employment with Le Chris? 2. How did you hear about this position? 3. Describe your feelings about people with mental illness and/or intellectual developmental disabilities. 4. Describe your experience (personally and professionally) with people who have a mental illness, and/or intellectual developmental disability. Application for Employment - questionnaire Page 3 of 4 Last Update:

5 APPLICATION FOR EMPLOYMENT: PRE-EMPLOYMENT DISCLOSURE AND AUTHORIZATION By signing my name below, I have been given an opportunity to review each of the following statements and authorize any inquiry into the statements made in this application as may be necessary in reaching an employment decision. I understand that any false or misleading information given on this application or during a preemployment interview, including a failure to disclose requested information, may result in my discharge. I understand that upon offer of employment I must consent to having an alcohol drug screening test as a condition of employment and that the outcome of this test and/or any subsequent investigations/inquiries may result in my discharge. I understand that any accident/incident will be considered just cause for a drug test. I understand that any employment relationship with Le Chris Inc., et al is at will ; meaning the employee may resign at any time and the employer may discharge the employee at any time with or without cause. I further understand that this at will employment relationship may not be changed. I understand that my employment is contingent upon all background checks meeting Le Chris standards. I AGREE TO HAVE MY CRIMINAL BACKGROUND CHECKED AND (check one): SWEAR AND AFFIRM TO NEVER HAVING BEEN CONVICTED OF A FELONY OR HAVE BEEN CONVICTED OF A FELONY IN THE PAST, BUT WOULD LIKE TO PROVIDE EXPLANATION AS TO THE CIRCUMSTANCES FOR IMPENDING CONSIDERATION OF EMPLOYMENT (USE ADDITIONAL SHEET(S) IF NECESSARY). Note: A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying. Printed Name Signature Date Application for Employment disclosure & authorization Page 4 of 4 Last Update: