Easter Seals North Georgia, Inc. Employment Application

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1 PERSONAL INFORMATION Last Name: First Name: Middle: DATE: Address: City: State: Zip: Home Phone: Alternate Number: Address: Are you legally eligible for employment in the United States? (Proof of eligibility will be required upon employment) Position Desired: Date Available: Salary Requirements: Location Desired: Have you previously worked at Easter Seals North Georgia (ESNG)? Do you have any relatives by blood or marriage employed with ESNG? If yes, provide dates, position(s) and location(s): If yes, provide name(s), relationship and location(s): EDUCATION High School: Years Completed: Diploma: OR GED: College or University: Years Completed: Degree Received: Major: Post Graduate: Degree Received: Major: Other Training or Degree: Years Completed: Degree Received: Major: Please list any training, certificates, professional licenses, or memberships (include expiration dates): (You need not disclose memberships or professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status or any other protected status.) Easter Seals North Georgia, Inc. 53 Perimeter Center East Suite 550 Atlanta, GA Page 1

2 RECORD OF CONVICTION Have you ever been convicted of a crime other than a minor traffic offense? If yes, please explain: (A conviction will not necessarily disqualify an applicant for employment. Factors such as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.) ALL CANDIDATES APPLYING FOR A CENTER STAFF POSITION MUST COMPLETE THE FOLLOWING SECTION Have you ever been shown by credible evidence (e.g. a court order or jury, a department investigation, or other reliable evidence) to have abused, neglected, or deprived a child or adult, or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct? If yes, please explain: Bright From the Start requires annual childcare training for all center staff. Are you willing to participate? Have you had Pediatric CPR Training within the past two (2) years? Expiration Date: Have you had Pediatric First Aid Training within the past three (3) years? Expiration Date: Have you had Fire Safety Training within the past three (3) years? Expiration Date: (If yes, please provide a copy of all current cards and certificates.) ALL CANDIDATES APPLYING FOR A CLERICAL OR OTHER OFFICE POSITION MUST COMPLETE THE FOLLOWING SECTION Data Entry: Numeric KPH Alpha-Numeric KPH Typing WPM Computer Skills: ALL CANDIDATES APPLYING FOR A DRIVER POSITION MUST COMPLETE THE FOLLOWING SECTION Driver s License Number: Class State: Easter Seals North Georgia, Inc. 53 Perimeter Center East Suite 550 Atlanta, GA Page 2

3 Please list all positions held, beginning with your current or most recent. ALL APPLICANTS MUST ACCOUNT FOR THE PAST TEN YEARS, INCLUDING ANY GAPS IN EMPLOYMENT. IF SELF-EMPLOYED, UNEMPLOYED, OR A STUDENT, PLEASE STATE AND LIST DATES. Easter Seals North Georgia, Inc. 53 Perimeter Center East Suite 550 Atlanta, GA Page 3

4 Easter Seals North Georgia, Inc. 53 Perimeter Center East Suite 550 Atlanta, GA Page 4

5 Easter Seals North Georgia, Inc. 53 Perimeter Center East Suite 550 Atlanta, GA Page 5

6 PROFESSIONAL REFERENCES Name and Title: Organization: 1 Phone: 2 Name and Title: Organization: Phone: 3 Name and Title: Organization: Phone: APPLICANT CERTIFICATION AND AGREEMENT I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Easter Seals North Georgia, Inc. to contact any company, educational institution, consumer reporting agency or other individual it deems appropriate to investigate my employment history, education credentials, driving record, character and qualifications, as permitted by law, and I give full and complete consent to such companies, consumer reporting agencies and/or individuals revealing any and all information they wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy or any other reason because of their statements. I hereby release Easter Seals North Georgia, Inc. from any/all liability of whatever kind and nature, which, at any time, could result from obtaining and having an employment decision, based on such information. I have reviewed and understand the duties of the position for which I have applied and can execute these assigned responsibilities. I consent to taking any post-offer employment physical examination, or pre-employment drug tests as may be required by Easter Seals North Georgia, Inc. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of Easter Seals North Georgia, Inc. However, I further understand that the policies, rules, regulations of employment, or anything said during the interview process shall not be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at-will and either Easter Seals North Georgia, Inc. or I may terminate my employment at any time with or without notice or cause. Print or Type Name: Signature of Applicant: Enter last 4 digits of social: Date: Easter Seals North Georgia, Inc. is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status. Easter Seals North Georgia, Inc. 53 Perimeter Center East Suite 550 Atlanta, GA Page 6

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