People Helping People - Still Family, LLC



Still Family, LLCEmployment ApplicationImportant:Please read and complete the application in its entirety. Applicants who have not fully completed the employment application will not be considered for employment.[Please print legibly].Today’s Date:Position Applying for: Personal Information:First Name:Middle Initial &/or Maiden Name : Last Name:Are you known to schools, references/past employers by another name??No?Yes, If yes please print that name below.First Name:Middle Initial &/or Maiden Name: Last Name:Home Phone Number()Work Phone Number()Cell Phone Number()Current Address:Email Address:How long have you lived at the above address?Have you lived out of the state of NC in the past 7 years? If yes, what state(s) did you live in?General Information:Yes ??NoHave you ever made application for employment with Still Family either full time or part time?Yes ??NoHave you made application for employment with Still Family in the last 90 days either full time or part time?Yes ??NoHave you ever been employed with Still Family either full time or part time?Yes ??NoDo you have a valid driver’s license? If no please explain why below?No North Carolina Drivers License?Explanation:?Car ?OtherWhat is your means of transportation to work?Yes ?NoHave you ever been convicted of a crime? If you please explain below.Explanation of conviction: (If additional space is needed please write on the back of this form. )Do you have two years of supervised experience in Mental Health, Developmental Disabilities, and/or Substance Abuse?No. If no please go directly to section BYes. If yes please complete section A and BSection A:Supervision history starting with the most recent:Indicate MH,DD, or SASupervisor’s NameSupervisor’s TitleCompany and Phone NumberNumber of Months SupervisedSection B.Employment History starting with the most recent employer:Employer:Type of Business:Address:Phone Number:Job title:Supervisor’s Name:Job description:Start Date:End Date:Final Wage:Reason for leaving:?Yes ?NoMay we contact this employer?Employer:Type of Business:Address:Phone Number:Job title:Supervisor’s Name:Job description:Start Date:End Date:Final Wage:Reason for leaving:?Yes ?NoMay we contact this employer?Employer:Type of Business:Address:Phone Number:Job title:Supervisor’s Name:Job description:Start Date:End Date:Final Wage:Reason for leaving:?Yes ??NoMay we contact this employer?Education and Skills:GED from Name:Address:Did you graduate? □ Yes □ NoHigh School Name:Address:Did you graduate? □ Yes □ NoTechnical School Name:Address:Did you graduate? □ Yes □ NoCurrently enrolled? □ Yes □ NoCollege/University Name:Address:Did you graduate? □ No □ Yes, if yes what is your degree in? Currently enrolled? □ Yes – what is your area of study? Graduate School Name:Address:Did you graduate? □ No □ Yes, if yes what is your degree in? Currently enrolled? □ Yes – what is your area of study? Other skills:MilitaryYes □ NoHave you ever been in the armed forces? If yes continue below.Branch:Discharge Date:Yes □ NoHonorable discharge?References: Students please list clinical & educational references with which you have had considerable contact:Name:Occupation:Phone #’sHome ()Work ()Cell()How do you know the above reference?Name:Occupation:Phone #’sHome ()Work ()Cell()How do you know the above reference?Name:Occupation:Phone #’sHome ()Work ()Cell()How do you know the above reference?Work AvailabilityWhen Can You Start:_?Phone Number: (H)(Cell) I am willing to drivenumber of minutes to work with a client.Please fill in the hours and days you can work. (Please be specific)Day of the WeekI can work the hours indicated below.Monday10 a.m. until 8 p.m.Day of the WeekI can work the hours indicated belowMondayTuesdayWednesdayThursdayFridaySaturdaySunday**Special Needs (example: can’t work first Monday of every month).Continue on the back of this form if needed**Please read the following statement carefully and indicate if you understand and agree.In submitting this application, I understand that:The submission of this application is not a promise (implied or otherwise) of an interview or employment.That a pre-employment interview is not a promise (implied or otherwise) of employment.I also understand that a final offer of employment will be based on results of a medical examination, background check, motor vehicle check, and possible drug screening. In addition I must provide evidence of my education, my automobile insurance and my valid driver’s license.Any misrepresentation of facts in this application or in connection with any medical examination will be just cause for rejection of my application.I understand that if hired I will be utilizing my vehicle for Still Family and I am responsible for maintaining liability, comprehensive and collision insurance on my automobile.I also understand that if hired my hourly wage includes mileage.I understand that Still Family does not guarantee a specific work schedule or job assignment.As a condition of employment, Still Family requires that it’s employees:Sign up for Payroll Direct Deposit.Maintain a valid driver’s license.Maintain required trainings and municate any changes and/or incidents concerning the consumer with the management municate any changes with my driver’s license or auto insurance.I understand that as a courtesy Still Family offers free OSHA, NCI, CPR/1st aid certifications. I understand that I have the option to take these trainings elsewhere at my expenses.I understand that if I utilize PrimeCare or the in house nurse for my physical I am responsible for payment.I hereby acknowledge that I have read and understand the above statements (1 throughAnd have not misrepresented the facts on this job application. Below I have indicated that I agree or I disagree to the above statements (1 through 10).I Agree??I DisagreeName:Date: Witness Name:Date: Still Family, LLCConsumer Reports ReleaseIn connection with my application for: a) employment (including contract for services), or b) residency, I understand that consumer reports or investigative consumer reports which may contain public record information, will be made on me including:Consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and others.These reports will include experience along with reasons for termination of past employment. Further I understand that you will be requesting information from various Federal, State and Local agencies regarding my past activities.I hereby authorize without reservation, any party or agency contacted by this employer to furnish the above-mentioned information.I understand I have the right to make a request of the Consumer Reporting Agency, upon proper identification and the payment of any authorized fees, the information in its files on me at the time of my request. I further authorize ongoing procurement of the above- mentioned reports at any time during my employment (or contract).Please PRINT the following informationName:Maiden: Street Address:City:St:Zip:Years at above Residence:Social Security Number:Date of Birth:Previous Address:City:St:ZIP:Years at Previous Residence:Drivers License State:License Number:Signature:created june 1, 2007Still Family, LLCConsent to Release InformationI understand that, as a condition of my consideration for employment (or continued employment) with Still Family, LLC, employment references will be contacted by phone or fax (or other means).Reference will be not limited to employment but, education verifications, social security verification, criminal and civil history, personal interviews, DMV records, any other public records and any other information bearing character, general reputation, personal characteristics and trustworthiness.I understand the above statement and I hereby authorize and consent to Still Family, LLC’s procurement of such information.Print Applicant or Employee NameDateSignature of Applicant’s or Employee’sDateSignature of WitnessDateStill Family, LLCEmployment ApplicationWhat You Will Need To Be Considered For Employment:Completed ApplicationResumeAuthorization for Release of InformationCriminal Record CheckMVR ReportValid NC Drivers LicenseProof of Automobile InsuranceSocial Security Card or Birth CertificateCompleted I-9 FormProof of EducationHigh School Diploma, College Diploma & Transcript or Highest Level of Education (Diploma & Transcript)Three References Confirming That You Are Eligible For EmploymentCurrent TBCPR/1st AidIf you are hired you will need to provide a voided check for direct deposit.Print Applicant’s Name: _______________________________Date:________Applicant’s Signature: ___________________________________ Date: _______Employment Application Questionnaire NAME:_____________________________ DATE:_______1.) Why are you interested in working with individuals with intellectual and developmental disabilities?2.) What qualities do you possess that would make you a good fit for our agency?3.) How would you handle an emergency situation with a client? What protocol would you take? Please be specific! ................
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