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1 WELCOME TO NATIONAL CENTER ON INSTITUTIONS AND ALTERNATIVES (NCIA) As you consider a career with NCIA and to gain a better understanding of our agency, please take few minutes to read the following information. Once you have read this page, please remove it from the application and keep for your personal reference. Name: Position Applied for: Date of Application: We are currently pre-screening all applications in the order in which they are received. Due to the volume of applications being received, this process may take 2-4 weeks. Candidates will be contacted as soon as possible. It is the mission of NCIA to help create a society in which all persons who come into contact with the human service or correctional systems will be provided an environment of individual care, concern and treatment. NCIA is dedicated to developing quality programs and professional services that advocate timely intervention and unconditional care. NCIA is an equal employment opportunity employer. Therefore, hiring and employment decisions at NCIA will be based on merit, qualifications, and abilities. NCIA does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. NCIA will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship. This policy and practice governs all aspects of employment, including selection, job assignment, promotion, compensation, discipline, termination, and access to benefits and staff training and development. Employment with NCIA is voluntarily entered into, and the employee is free to resign at will at any time, with or without cause. Similarly, NCIA may terminate the employment relationship at will at any time, with our without cause, so long as there is no violations of applicable federal or state law. An offer of employment with NCIA is not intended to create a contract, nor is it to be construed to constitute contractual obligations of any kind or a contract of employment between NCIA and any of its employees. NCIA s Substance Abuse policy promotes our desire to provide a drug-free, healthful, and safe workplace. Therefore, while on NCIA premises and while conducting business-related activities off NCIA premises, no employee may use, possess, distribute, sell or be under the influence of alcohol or illegal drugs. Accordingly, NCIA will maintain pre-employment screening practices designed to prevent hiring individuals who are current users of illegal drugs. Employees will not be permitted to work while under the influence of drugs or alcohol. Page 1 of 8

2 Individuals who appear to be unfit for duty may be subject to a medical evaluation, which may include drug or alcohol screening. Refusal to comply with fitness-for-duty evaluation may result in disciplinary action up to and including termination of employment. To ensure that individuals who join NCIA are well qualified and have a strong potential to be productive and successful, it is the policy of NCIA to conduct a criminal background check on each new employee. Due to regulations that govern the licenses of the programs that we operate, certain criminal background offenses and/or the time frame of some offenses may preclude an applicant from being considered for some positions at NCIA. Therefore, please provide NCIA with a complete and accurate criminal background history. NCIA will also check employment and personal references, and educational background of all applicants being considered for employment. Please be sure to give complete name, address, and phone numbers of past and present employers, educational institutions, and personal references. Additionally, if an employment offer is made, you will be required to submit educational documentation on the day you complete your new hire paperwork. A condition of initial and continued employment for NCIA direct care positions is the completion of, and required renewal of the Certified Mediation Technician (CMT) certification. Initially this requires completion of our 20 hour CMT course and a Maryland Board of Nursing (MBON) application, documentation of any and all criminal background history, presentation of a 2 X 2 passport photo and an application fee of $20. Renewal requirements include providing MBON with any change of address since the initial application, completion of a 4 hour recertification course, completion of the renewal application and a renewal fee of $30. If an employment offer is made, you will also be required, as a condition of employment, to complete the Employment Eligibility Verification Form, I-9, and present documentation establishing identity and employment eligibility on the day that you complete your new hire paperwork. (A copy of the accepted documentation to fulfill this obligation can be obtained by contacting the Employment Specialist.) NCIA intends to provide a work environment that is pleasant, healthful, comfortable and free from intimidation, hostility, or other offenses, which might interfere with work performance. Sexual harassment and other types of harassment are against the law and they affect employee morale and interfere with our performance. Therefore, sexual harassment and any other unlawful harassment will not be tolerated. To help ensure that employees are able to perform their duties safely, medical examinations will be required of all direct care employees or any position that requires an employee to come in close contact with the individuals we support on a regular basis. After an offer has been made to an applicant entering a position of direct care, a medical examination will be performed at the employee s expense. The new employee will be required to present a doctor s certification that they are free from TB, Hepatitis B, and any other communicable diseases within 7 business days of their hire date, unless program regulations indicate differently. Direct care staff will be required to present an annual certification as a condition of continuing employment. THANK YOU FOR YOUR INTEREST IN NCIA CAREER OPPORTUNITIES. NATIONAL CENTER ON INSTITUTIONS & ALTERNATIVES 7205 Rutherford Road Baltimore, Maryland Phone: Fax: Website: Page 2 of 8

3 NATIONAL CENTER ON INSTITUTIONS & ALTERNATIVES 7205 Rutherford Road, Baltimore, Maryland Phone: APPLICATION FOR EMPLOYMENT ACKNOWLEDGEMENT By my initials I acknowledge that I have read and understand the statements and polices described in the (Welcome document need to name it). Today s Date: Position and/or Program Applying for: PERSONAL INFORMATION NAME: First: MI: Last: Do you have a valid Driver s License? Yes No Do you have a provisional or permit? Yes No Driver s License Number: Driver s License Expiration Date: Are you 21 years or older? Yes No Is there any information regarding your current name or use of another name that NCIA would require in obtaining employment reference or criminal background information? Yes No If Yes, please provide necessary information. Present Address: Apt. City: State: Zip Code: How long have you been at your present address? Have you lived in another state in the past 10 years? Yes No If Yes, please list the cities, state(s), & years. : Home Phone: Work Phone: Cell Phone: Address: ADDITIONAL INFORMATION How did you learn about NCIA? Referred by Employee (Name/Position/Relationship) School/College Friend/Relative (Not Employee) Newspaper Maryland Job Service Internet Job Board NCIA Website Other Have you ever been employed with NCIA? Yes No If Yes: Start Date: End Date: Position(s): Why did you leave? Do you have relatives currently employed with NCIA? Yes No If Yes: Name: Relationship: Position: Are you legally eligible for employment in the United States? Yes No In order to comply with the Immigration Act of 1986, a new employee must supply documents that provide identity and employment eligibility within three (3) business days of hire in order to complete the I-9 form. Because of the importance of this requirement, its receipt is a condition of your employment. Page 3 of 8

4 Have you ever been convicted of ANY crime, other than traffic violations? Yes No If yes, please provide information. NCIA performs criminal background checks on all employees. Failure to provide complete and accurate information constitutes falsification of documents and could preclude you from employment with NCIA. Charge(s) Conviction Date Felony or Misdemeanor? Disposition If you are applying for a direct care position, do you have any condition that would preclude you from performing physical restraint if necessary? Yes No Due to the nature of the work environment at NCIA, physical restraint of individuals may be required. For safety reasons, the ability to perform this function is an essential function for all direct care staff. If a job offer is made, how soon will you be available to work? Do you have any objections to work overtime? Yes No Can you work overtime without prior notice? Yes No EDUCATION Please list your educational background. Include GED, High School, College and/or Technical & Trade Schools. If a job offer is extended, you will be required to provide educational documentation at time of employment. Name, Address of School # of Yrs. Grad? Y/N Degree Major ADDITIONAL RELATED TRAINING Include all other training relevant to the position for which you have applied (i.e. CPR, First Aid, DDA & YIT Training, Med Administration, Computer Skills, and workshops attended. Please include date training was completed and expiration dates. Use additional sheets as required. Training Date (Month/Year) Expiration Date Where Received PROFESSIONAL REFERENCES Name: Relationship to you: Occupation: Address: City: State: Zip: Phone: Day: Evening: Years Known: Name: Relationship to you: Occupation: Address: City: State: Zip: Phone: Day: Evening: Years Known: Name: Relationship to you: Occupation: Address: City: State: Zip: Phone: Day: Evening: Years Known: Page 4 of 8

5 EMPLOYMENT HISTORY Please provide a complete and accurate job history for at least the last 6 years, beginning with the most recent. Use additional sheets as required. NCIA performs employment reference checks on all employees. Failure to provide complete and accurate information could preclude you from employment with NCIA. Current (or most recent) Employer: Job Title: Supervisor: Employed: From (MM/YY) Phone: To (MM/YY) FT or PT? Salary: If Current, may we contact? Yes No Duties: If Current, do you anticipate leaving if offered a position? Yes No Reason for Leaving: Previous Employer: Job Title: Supervisor: Employed: From (MM/YY) Phone: To (MM/YY) FT or PT? Salary: Duties: Reason for Leaving: Previous Employer: Job Title: Supervisor: Employed: From (MM/YY) Phone: To (MM/YY) FT or PT? Salary: Duties: Reason for Leaving: Previous Employer: Job Title: Supervisor: Employed: From (MM/YY) Phone: To (MM/YY) FT or PT? Salary: Duties: Reason for Leaving: Other Employment and/or Volunteer Work: Provide a summary of any other employment or volunteer activities (beyond the required 6 years) that would be relevant to the position for which you are applying. Page 5 of 8

6 NCIA IS AN EQUAL OPPORTUNITY EMPLOYER. WE WILL NOT DISCRIMINATE IN REGARDS TO AGE, SEX, RACE, NATIONAL ORIGIN, RELIGIOUS BELIEF OR PRACTICE, MARITAL STATUS, POLITICAL AFFILIATION, SEXUAL ORIENTATION OR DISABILITY. UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICATION FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100. Applicant s Signature: Date: CHECK YOUR APPLICATION TO ENSURE THAT YOU HAVE ANSWERED EVERY QUESTION COMPLETELY AND ACCURATELY. Only applications that are completed in their entirety will be considered for open positions with NCIA. This includes complete and correct addresses, phone numbers, and employment dates. I certify that the information I have provided on this application and any resume is true and complete and that I have not knowingly withheld any information that would affect my application. I understand that any misrepresentation, omission or concealment of facts is cause for dismissal. I authorize investigation of all statements contained in the application and resume. In entering into employment with National Center on Institutions and Alternatives, Inc. (NCIA), I agree to observe all rules of my employer and to perform satisfactorily such duties as may be assigned to me. I understand that employment with NCIA is voluntarily entered into, and I am free to resign at will at any time, with or without cause. Similarly, NCIA may terminate the employment relationship at will at any time, with or without cause, so long as there is no violation of applicable federal or state law. I understand that my employment is for no definite or fixed period of time. I understand that any continuation of employment shall depend upon performance that is satisfactory at all times to my employer. Also, neither hours nor work, which may be assigned to me at any time, nor any other act or circumstance, shall constitute a guarantee of employment or continuation of assigned hours or work. Applicant s Signature: Date: I understand that if I am employed by NCIA I will be required to have a criminal background check conducted and submit to a urinalysis, both at the expense of NCIA. I further understand that an initial physical examination and physician s certificate will be required (in most positions), at my expense. I also understand and agree to provide an annual re-certification of my health, also at my expense. Applicant s Signature: Date: I understand that most positions require the successful completion of specific trainings and re-certifications to the position as mandated by the regulatory agencies that license NCIA. I understand that failure to attend or successfully complete this required training will preclude me from continued employment with NCIA. Applicant s Signature: Date: Page 6 of 8

7 STATEMENT REGARDING HOURS OF AVAILABILITY Name: Position Applying For: NCIA understands that employees have interests and obligations other than their work. We encourage our employees to pursue family involvement, religious activities and continued education. We realize that it is necessary to work around other obligations such as childcare and other employment. Therefore, in an effort to make the scheduling process most effective and satisfying for both the employee and supervisor we are requiring each applicant to submit their exact hours of availability, keeping other interests and obligations in mind. Submitting your availability does not guarantee a specific schedule, a specific amount of hours, or the change of any published schedule. Your submission of your hours of availability will not excuse you from meeting your training requirements. IF APPLYING FOR DIRECT CARE PLEASE MARK ANY AND ALL HOURS/SHIFTS THAT YOU ARE AVAILABLE FOR WORK. Please note: Typical hours for staffing our Residential houses are Monday Friday between the hours of 3 pm and 8 or 9 am as well as 24 hours on weekends and holidays. Direct Care Residential Staff will be expected to work during these hours/shifts. 7am 3pm 8am 4pm 3pm 11pm 4pm 12 midnight 11pm 7am 11pm 9 am 12 midnight 8am SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY I acknowledge that the submission of my Hours of Availability does not constitute a guarantee of a specific schedule or a specific amount of hours. I also acknowledge that my Hours of Availability does not preclude me from meeting my training obligations. Applicant s Signature: Date: I am aware that this information will become a part of my personnel file and be used in the creation of my work schedules. If my hours of availability change, I must give notice to my Supervisor 30 days prior to the change. I understand that my scheduled hours may be reduced due to my new hours of availability. Applicant s Signature: Date: Page 7 of 8

8 National Center on Institutions and Alternatives 7205 Rutherford Road Baltimore, MD Phone: AUTHORIZATION TO VERIFY INFORMATION It is the policy of the National Center on Institutions and Alternatives (NCIA) to verify current/previous employment, transcripts from educational institutions, conduct criminal background checks and obtain any other information required by the licenses under which NCIA operates. Please sign the bottom of this page to authorize the release of the necessary information. I authorize to provide the requested information to the National Center on Institutions and Alternatives (NCIA). I release your company and its employees from all liability from any damage that may result from providing such information. I hereby consent to NCIA verifying all the information I have provided on this application form. I also agree to execute as a condition of employment or a condition of continued employment any additional written authorizations necessary for the company to obtain access to and copies of records pertaining to this information. I also hereby authorize NCIA s access to any medical histories or records pertaining to me (and any other individuals who, due to my employment, may be covered by any company medical or other insurance program). With regard to the foregoing disclosures, I hereby agree to release any person, company, or other entity from any and all causes of action that otherwise might arise from supplying NCIA with information it may request pursuant this release. I understand that any false answers or statements, or misrepresentations by omission, made by me on the application may be cause for my immediate discharge, even when such falsifications or misrepresentations are discovered after I am employed. Applicant s Name (Print): Applicant s Signature: Date: Thank you for your cooperation. Page 8 of 8

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