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|APPLICATION FOR EMPLOYMENT |

|Hope Services, LLC |

Instructions to Applicants

TO BE CONSIDERED FOR STATE EMPLOYMENT, YOU MUST ANSWER ALL QUESTIONS AND COMPLETE ALL SECTIONS OF THIS APPLICATION FORM.

HOPE SERVICES EMPLOYS ONLY US CITIZENS OR ALIENS WHO CAN PROVIDE PROOF OF IDENTITY AND WORK AUTHORIZATION WITHIN 3 WORKING DAYS OF EMPLOYMENT.

WHEN COMPLETING THIS APPLICATION, PLEASE MAKE SURE YOU

COMPLETE THE SECTION FOR EQUAL OPPORTUNITY INFORMATION.

GIVE COMPLETE INFORMATION ON YOUR EDUCATION AND WORK HISTORY (“SEE RESUME” IS NOT ACCEPTABLE).

LIST SEPARATELY EACH JOB HELD AND YOUR DUTIES FOR EACH POSITION WHEN YOU WORKED FOR ONE EMPLOYER AND HELD MORE THAN ONE POSITION.

CHECK FOR ACCURACY, SIGN AND DATE YOUR APPLICATION.

THANK YOU FOR YOUR INTEREST IN WORKING WITH OUR AGENCY. HOPE SERVICES WANTS TO FIND THE BEST QUALIFIED PEOPLE AVAILABLE TO SERVE ITS CONSUMERS. ALTHOUGH EVERYONE WHO APPLIES CANNOT BE HIRED, YOUR APPLICATION WILL BE GIVEN EVERY CONSIDERATION.

|Equal Opportunity Information |

|HOPE Services policy prohibits discrimination based on race, sex, color, creed, national origin, age or disability. The information requested below will in no|

|way affect you as an applicant. Its sole use will be to see how well our recruitment efforts are reaching all segments of the population. |

|Date of Birth |DISABILITY: “Disability means, with respect to an individual: (1) a physical or mental impairment that substantially |

| |limits one or more of the major life activities of such individual; (2) a record of such an impairment; or (3) being |

|(Month) (Day) (Year) |regarded as having such an impairment” (Americans with Disabilities Act of 1990). Persons without a disability should |

| |check item A. |

|Gender |The reporting of a disability is strictly VOLUNTARY. Persons with disabilities who DO NOT WISH to report their |

| |disabilities should check item A. Information reported on this form will be kept confidential as required by State law. |

|Male Female |Public disclosure of this information without your consent would be a violation of G.S. 126-27. |

| ETHNIC GROUP |A None/Prefer not to report |G Respiratory impairment |

|1. White (non-Hispanic) |B Blind or severely visually |H Nervous system/Neurological |

|2. Black (non-Hispanic) |impaired |disorder |

|3. Hispanic (Mexican, Puerto Rican, Cuban, Central or |C Deaf or severely hearing |I Mentally restored |

|South American, other Spanish origin regardless of |impaired |J Mental retardation |

|race) |D Loss of limited use of arms |K Learning disability |

|4. Asian (including Pacific |and/or hands |L Others (heart disease, diabetes, |

|Islander) |E Non-ambulatory (must use |speech impairment) |

|5. American Indian (including |wheelchair) |M Other (please specify) |

|Alaskan native) |F Other orthopedic impairment |______________________ |

| |(including amputation, arthritis, | |

| |back injury, cerebral palsy, spina | |

| |bifida, etc.) | |

|APPLICATION FOR EMPLOYMENT |HOPE Services,LLC |Date of Application |

|(SSN Voluntary, for Record Keeping and Data Processing Only) | | |

|Social Security Number |Last Name |First Name |Middle Name |

| | | | |

|Address (Street number and name) |City |County |

| | | |

|State |Zip Code |Phone (Home or where you can be reached) |Business Phone |

| | | | |

|Email Address |

| |

|Availability | | |

|Are you available to |Are you related by blood or marriage to any person now working for this agency? YES NO | |

|begin work in two |If yes, give name, relationship to you and the program where they are employed. | |

|weeks? | | |

|YES NO | | |

|CHECK the types of work you will accept: 1. Permanent full-time 2. Permanent part-time 3. Temporary full-time 4. Temporary part-time If you are not |

|available for work now, enter the earliest date you could begin work (mo/day/yr.) |

|Availability: (1st=7am-3pm; 2nd=3pm-11pm; 3rd=11pm-7am) ( Mon 1st 2nd 3rd); (Tues1st 2nd 3rd); |

|(Wedn 1st 2nd 3rd);(Thur1st 2nd 3rd); (Fri1st 2nd 3rd); (Sat1st 2nd 3rd); (Sunday1st 2nd 3rd) |

|Job Applied For |

|Enter below the specific title of the job for which you are applying. |

|1. |

|Referral Source |

|Please indicate your referral source: |

|If you were referred by the Employment Security Commission (Job Service) please indicate which local office: |

|Education |

|Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED College 1 2 3 4 Graduate School 1 2 3 4 |

|Under S/Q Hrs., list the hours of credit received and if they were semester (S) or quarter (Q) hours. |

| | |Dates Attended (mo/yr) | | | |Type of Degree |

|Schools |Name and Location |From: To: |Grad? |S/Q Hrs. |Major/Minor Course Work |Received |

| | | |YES | | | |

|High School | | |NO | | | |

|Graduate or | | |YES | | | |

|Professional | | |NO | | | |

|Other educational, | | |YES | | | |

|vocational school, | | |NO | | | |

|internships, etc. | | | | | | |

|Special training programs and seminars you have completed in the last five years (list): |

| |

|Driving Record: |DO NOT COMPLETE THIS BLOCK |

|Please list any traffic violations/accidents which you have had in the past 3 years: |Driving Record and Criminal Record |

| |Have been verified |

|Please indicate how many points are currently on your drivers license:_____ |Will be verified prior to employment |

| |Person Responsible: |

|Licenses and certifications (List, giving dates and sources of issuance): |

| |

| |

| | Sign Language | Legal transcription |

|Driver’s License |Foreign language (specify) |Medical transcription |

|Number State |Adding Machine/calculator |Braille |

| |Typing (specify WPM) |Word Processing |

|Car for use at work |Shorthand/speedwriting (specify WPM) |Other |

|Have you ever been convicted of an offense against the law other than a minor traffic violation? (A conviction does not mean you cannot be hired. The offense |

|and how recently you were convicted will be evaluated in relation to the job for which you are applying.) YES NO (If yes, explain fully on an additional |

|sheet.) |

| |

| |

| |

| |

| |

| |

|DO NOT COMPLETE THIS BLOCK |

|DEGREES AND PROFESSIONAL CREDENTIALS |

|Have been verified Need to be verified Prior to Working (G.S. 126-30) Person Responsible: |

|WORK HISTORY (include volunteer experience) Use Additional Sheets if Necessary |

|Current or Last Employer: |Address: |

|(1) | |

|Job Title: |Supervisor’s Name |Telephone Number |No. Supervised by you: |

| | | | |

|Date Employed (mo/yr) |Starting Salary |Ending or Current Salary |Reason for Leaving |May We Contact Employer |

| |$ per |$ per | |YES NO |

|Date Separated (mo/yr) |List major duties in order of their importance in the job: |

| | |

|Full Time Years Months | |

| | |

|Part Time Years Months | |

| | |

|If part time, number of hours worked | |

|per week: | |

|Employer: |Address: |

|(2) | |

|Job Title: |Supervisor’s Name |Telephone Number |No. Supervised by you: |

| | | | |

|Date Employed (mo/yr) |Starting Salary |Ending or Current Salary |Reason for Leaving |

| |$ per |$ per | |

|Date Separated (mo/yr) |List major duties in order of their importance in the job: |

| | |

|Full Time Years Months | |

| | |

|Part Time Years Months | |

| | |

|If part time, number of hours worked | |

|per week: | |

|Employer: |Address: |

|(3) | |

|Job Title: |Supervisor’s Name |Telephone Number |No. Supervised by you: |

| | | | |

|Date Employed (mo/yr) |Starting Salary |Ending or Current Salary |Reason for Leaving |

| |$ per |$ per | |

|Date Separated (mo/yr) |List major duties in order of their importance in the job: |

| | |

|Full Time Years Months | |

| | |

|Part Time Years Months | |

| | |

|If part time, number of hours worked | |

|per week: | |

|I certify that I have given true, accurate and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection|

|with my work, I authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available |

|concerning my qualifications. I authorize investigation of all statements made in this application and understand that false information or documentation, or a|

|failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal |

|action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: |

|G.S. 126-30, G.S. 14-122.1.) |

| | |

|Signature of Applicant (unsigned applications will not be processed) |Date |

| Employer: |Address: |

|(4) | |

|Job Title: |Supervisor’s Name |Telephone Number |No. Supervised by you: |

| | | | |

|Date Employed (mo/yr) |Starting Salary |Ending or Current Salary |Reason for Leaving |May We Contact Employer |

| |$ per |$ per | |YES NO |

|Date Separated (mo/yr) |List major duties in order of their importance in the job: |

| | |

|Full Time Years Months | |

| | |

|Part Time Years Months | |

| | |

|If part time, number of hours worked | |

|per week: | |

|Employer: |Address: |

|(5) | |

|Job Title: |Supervisor’s Name |Telephone Number |No. Supervised by you: |

| | | | |

|Date Employed (mo/yr) |Starting Salary |Ending or Current Salary |Reason for Leaving |

| |$ per |$ per | |

|Date Separated (mo/yr) |List major duties in order of their importance in the job: |

| | |

|Full Time Years Months | |

| | |

|Part Time Years Months | |

| | |

|If part time, number of hours worked | |

|per week: | |

|Employer: |Address: |

|(6) | |

|Job Title: |Supervisor’s Name |Telephone Number |No. Supervised by you: |

| | | | |

|Date Employed (mo/yr) |Starting Salary |Ending or Current Salary |Reason for Leaving |

| |$ per |$ per | |

|Date Separated (mo/yr) |List major duties in order of their importance in the job: |

| | |

|Full Time Years Months | |

| | |

|Part Time Years Months | |

| | |

|If part time, number of hours worked | |

|per week: | |

|I certify that I have given true, accurate and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection|

|with my work, I authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available |

|concerning my qualifications. I authorize investigation of all statements made in this application and understand that false information or documentation, or a|

|failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal |

|action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: |

|G.S. 126-30, G.S. 14-122.1.) |

| | |

|Signature of Applicant (unsigned applications will not be processed) |Date |

Pre Screen Questionnaire

1. Are you familiar with what a Person Centered Plan (PCP) is? Have you ever developed, revised or used one?

2. Are you familiar with NCI techniques? Have you ever used therapeutic holds or physical restraints?

3. How many months or years full time equivalent experience do you have working directly with children in the mental health field?

4. What are your salary requirements?

5. Please list at least three professional references (list name, job title, relationship and phone number).

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