Employment Application

Thank you for submitting your application.

default

Our company (“CSS Healthcare Services”) fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. As an Equal Opportunity Employer, we intend to comply fully with applicable federal, state and/or local employment laws and the information requested on this application will only be used for purposes consistent with those laws. To the extent required by applicable law, CSS Healthcare Services maintains a drug-free workplace.

Position Applied For

Date

Personal Data

Name

County of Residence

Current Address

City

State

Zip

Permanent Address

Permanent City

Permanent State

Permanent Zip

Home Number

Alternate Number

Last Four Digits of Social Security No.

Are there any days, shifts or hours you will not work?

Yes

If yes, please explain

*Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.

When will you be available to start work?

How did you learn of our Company?

Have you ever applied or worked at CSS before?

Yes

If yes, provide dates:

Driver's License Number

State that Issued Driver's License

Are you legally authorized to work in the United States?

Yes

*Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

DRIVING RECORD

Answer only if driving is a requirement of the job for which you are applying. (All CNA and Direct Support applicants MUST complete the driving record)

Do you have a valid diver's license?

Yes

Have you had any tickets?

Yes

If yes, please explain

EMPLOYMENT HISTORY

Please complete for ALL full-time or part-time employment for the past 5 years, beginning with MOST RECENT employer. You may include as part of your employment history any verified work performed on a volunteer basis.

Company Name

Phone

Address

Name of Supervisor

May We Contact

Yes

Employed Date: From

Rate of Pay: Start

Last

Reason for leaving:

Company Name

Phone

Address

Name of Supervisor

May We Contact

Yes

Employed Date: From

Rate of Pay: Start

Last

Reason for leaving

Company Name

Phone

Address

Name of Supervisor

May We Contact

Yes

Employed Date: From

Rate of Pay: Start

Last

Reason for leaving

Company Name

Phone

Address

Name of Supervisor

May We Contact

Yes

Employed Date: From

Rate of Pay: Start

Last

Reason for leaving

Have you ever been discharged or asked to resign from a job?

Yes

If yes, explain:

Did you receive any disciplinary action (write-ups, warnings, suspension, etc.) in your last 12 months of active employment with a previous employer?

Yes

If yes, explain:

Were you given a performance evaluation within the last 12 months of active employment?

Yes

If yes, what was the range of scores used and what was your score?

Have you ever filed a claim against a previous employer?

Yes

If yes, explain:

WORK REFERENCES

Please list TWO previous employers that we may contact to complete a work reference on your behalf.

Company Name

Address

Phone

Name of Supervisor

Fax

Position Held

Reason for leaving

Employment Start Date

End Date

Starting Pay Rate

End Pay Rate

Company Name

Address

Phone

Name of Supervisor

Fax

Position Held

Reason for leaving

Employment Start Date

End Date

Starting Pay Rate

End Pay Rate

EDUCATION

Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:

High School

Graduated

Yes

High School Grade Point/Overall GPA

College/University

Graduated

Yes

If no, Degree Credits Earned

Type of Degree Received or Expected

Major

Minor

Grade Point/Overall GPA

Graduate School/PhD

Graduated

Yes

If no, Degree Credits Earned

Type of Degree Received or Expected

Major

Minor

Grade Point/Overall GPA

Technical College/GED Program

Graduated

Yes

If no, Degree Credits Earned

Type of Degree Received or Expected

Major

Minor

Grade Point/Overall GPA

Licenses/ Certification/Other

Licenses/Certifications Current?

Yes

If no, Which are Expired

APPLICANT’S ACKNOWLEDGMENT

I certify that the answers given herein and during the entire application process (including but not limited to any criminal record inquiries made following this application, resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge.

I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.

I consent to and authorize CSS Healthcare Services to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment.

I further authorize the listed employers, schools and personal references to give CSS Healthcare Services (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party for providing a good faith reference.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY BE TERMINATED BY ME OR CSS HEALTHCARE SERVICES WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTE AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND CSS. I ALSO UNDERSTAND THAT THIS EMPLOYMENT IS ON A PART-TIME BASIS AND NO AMOUNT OF HOURS IS GUARANTEED. HOWEVER, MORE HOURS MAY BE ASSIGNED AS CLIENTS’ NEEDS ARISE.

ADMINISTRATIVE APPLICANTS ONLY: Full time employment may be offered depending on qualifications and organization needs at the time of hire.

I understand I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination; submit to a background investigation or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the release of any background check results and of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document. I agree to sign any additional forms necessary for pre-employment checks and/or tests to be conducted.

CERTIFICATION FOR ALL APPLICANTS – PLEASE READ CAREFULLY

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Name

Date