Imagining possibilities and eliminating barriers in an ever changing world. . Application for Employment

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1 Imagining possibilities and eliminating barriers in an ever changing world.. Application for Employment Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resource Department. Providence Place is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. Fill out the application completely. Please print clearly. If questions are not applicable, enter N/A, do not leave blank. Be sure to sign when completed. Resumes will not be accepted in lieu of applications, unless specifically stated in the job vacancy notice. PERSONAL Name: Last First Middle Maiden Present address: Street Number & Name City, State Zip How long at this address: Address: Main Telephone Number: ( ) Other: ( ) Driver s License number: Expiration date: State of Issue: Have you received a moving violation within the last 12 months? Yes No If yes, please explain: Your insurability as a driver by our insurance company, may determine employment depending upon the position you are applying for. Are you legally eligible for employment in this country? No Yes Date available for work? Are you at least 17 years of age? Yes No (Hiring is subject to verification that you are of minimum legal age.) Have you ever worked for Providence Place before: No Yes If Yes, when? Employment desired: FULL-TIME ONLY PART-TIME ONLY FULL-OR PART-TIME Position(s) applying for: 1) 2) Desired Salary (Be specific) $ Yearly Hourly How many hours per week can you work? Can you work nights/weekends? No Yes Days/times available to work: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

2 EDUCATION NOTE: Applicants will be required to provide proof of diploma, degree, transcripts, licenses, certifications, and registrations upon hire date. High school graduate or GED? Yes No If GED, what is the name and address of the institute you received your GED from? TYPE OF SCHOOL COMPLETED NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YEARS MAJOR & DEGREE High School College Business or Trade School Professional School Occupational License, Certificate or Registration Occupational License, Certificate or Registration Number Where Issued Expiration Date Number Where Issued Expiration Date Have you ever been convicted of a felony or subjected to deferred adjudication on a felony charge? Yes No If your answer is "Yes," explain, in detail, in the space below. Please provide the following information: dates and nature of the offense; name and location of the court; and disposition of the case(s). A conviction may not disqualify you, but a false statement will. Note: Some state agencies may require additional information related to convictions of misdemeanors. JOB RELATED INFORMATION Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company? Yes No If Yes please explain: Have you ever been involuntarily terminated from a position of employment? Yes No If yes, please explain: (This question does not apply to a layoff or reduction in force for economic reasons)

3 WORK EXPERIENCE If you were self- Please list your work experience for the past five years beginning with your most recent job held. employed, please give the name of your company. Attach additional sheets if necessary.

4 Please explain any gaps in your employment, other than those due to personal illness, injury or disability. OFFICE SKILLS Approximately how many words per minute do you type? 10 Key: Site Touch Sign Language (if required for this position) Yes No Are you a certified interpreter? Yes No Do you speak a language other than English? Yes No How fluently: Fair Good Excellent If yes, what language(s) do you speak? Microsoft Office: Excel Word Quickbooks Outlook Powerpoint Other Special Training/Skills: REFERENCES Please list two references other than relatives or previous employers. Name: Position: Company: Name: Position: Company: Phone Number: ( ) - Phone Number: ( ) - Address: Address: MILITARY Have you ever been in the Armed Forces? Yes No Are you now a member of the National Guard? Yes No Branch of Service: Date Entered: Discharge Date:

5 DISCLAIMER & SIGNATURE PLEASE READ CAREFULLY I certify that I have fully and accurately answered all questions and have given all information requested in this application for employment, and I understand that any wrong or incomplete information on the form may disqualify me for further consideration for employment or, if discovered after I am hired, may be grounds for my immediate dismissal. I understand that all such information is subject to verification by Providence Place, and hereby give my consent to Providence Place to investigate my background and qualifications using any means, sources, and outside investigators at its disposal. I agree to undergo any type of drug and/or alcohol testing that the Organization may require at any time. I, (name of applicant), agree to immediately notify Providence Place if I am convicted of, receive deferred adjudication in, or otherwise plead guilty or no contest to a felony, or any crime involving violence, dishonesty or a breach of trust, while my application is pending or during my period of employment, if hired. Not informing Providence Place could be grounds for termination. I understand that this employer does not unlawfully discriminate in employment and no questions on this application are used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. If I am hired, I understand that Providence Place is an At-Will employer and I am free to resign at any time, with or without cause and with or without prior notice, and Providence Place reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Chief Executive Officer of Providence Place. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer s service, whenever it is discovered. Signature of Applicant Date This Company is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications. Thank you for completing this application form and for your interest in our organization.

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