ATTENTION APPLICANTS!

Transcription

1 6040 Radio Station Road La Plata, Maryland Employment Application AN EQUAL OPPORTUNITY EMPLOYER WE PROMOTE A DRUG FREE WORKPLACE ATTENTION APPLICANTS! Spring Dell Center receives many applications daily for your application to be considered, it must be completed in its entirety. All positions require a valid driver s license and an acceptable driving record unless otherwise noted. Spring Dell Center s insurance may not cover new staff if they have a certain number of points on their driving record. Spring Dell Center, Inc. s policy is that you must submit along with your application a complete driving record history unless otherwise noted. You can obtain this at the MVA or online at for a cost of $9.00. We apologize for any inconvenience to you, but applications will not be processed without this record. We appreciate your help in obtaining this record. We consider all applicants for all positions without regards to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition, handicap or any other legally protected status. Thank you for your interest in working for Spring Dell Center. Spring Dell Center, Inc. is dedicated to assisting individuals with disabilities in achieving their highest level of independence by providing support and opportunities for the quality of life they desire within their community.

2 Connecting people with disabilities to the community and employment Annual Leave Sick Leave Maternity Leave EMPLOYEE BENEFITS Adoption/Paternity Leave Paid Training Military Leave Court Leave Time off for Religious Observances Workmen s Compensation Social Security Membership in the State Employee s Credit Union Paid Travel Expenses Direct Deposit Health Insurance (Agency pays 65% of premium) 1. Care First Blue Choice HMO Option with prescription 2. Regional Traditional Dental Free $10,000 Life Insurance/Accidental Death and Disbursement Tax Shelter Annuity (50% match up to $3,000 per year) Tuition Reimbursement Bereavement Leave Paid Holidays (10) SDC Employment Application REV 04/30/15 Page 2

3 DATE OF APPLICATION: Spring Dell Center, Inc., Employment Application PLEASE PRINT POSITION(S) APPLIED FOR: Interested in working. Full-Time Part-Time Substitute NAME: LAST FIRST: MIDDLE: MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE: CELL PHONE: ADDRESS: What date are you available to begin work? Do you have transportation? YES NO Are you able to transport individuals in your vehicle, if needed? YES NO Do you have a valid driver s license? If yes, driver s license number and state: YES NO Do you have more than 2 points on your driving record? YES NO If applying for a direct care or van driver position, are you 18 years or older? YES NO If employed and you are under 18, can you furnish a work permit? YES NO Have you ever applied here before? If yes, date: YES NO Have you ever been employed here before? If yes, date: YES NO Are you employed now? YES NO If employed, may we contact your current employer? YES NO Are you prevented from lawfully becoming employed in this country because of Visa/Immigration status? YES NO Are you currently on The List of Excluded Individuals and Entities or LEIE for the Federal Government or the State of Maryland? (You would have been notified by mail) YES NO Have you been convicted of a criminal offense? Conviction will not necessarily disqualify you from employment. YES NO IF APPLYING FOR RESIDENTIAL POSITIONS COMPLETE THIS SECTION Do you have a vehicle that can stay with you while at work? YES NO Are you willing to work (Circle all that apply) A.M. Shifts (5:00 am 8:00 am) YES NO P.M. Shifts (3:00 pm 11:00 pm) YES NO Sleepover Shifts (10:00 pm 7:00 am) YES NO Every Other Weekend YES NO Holidays YES NO 7 Days On / 7 Days Off YES NO SDC Employment Application REV 04/30/15 Page 3

4 Spring Dell Center, INC. Employment Application WORK HISTORY List your employment history, beginning with your current or most recent position held. PLEASE PRINT. Please Do Not Write See Resume JOB NUMBER 1 EMPLOYER S NAME: SUPERVISOR: STREET ADDRESS: CITY: STATE: ZIP: DATES EMPLOYED FROM: TO: SALARY: DUTIES: PHONE NUMBER: FAX NUMBER: YOUR JOB TITLE: REASON FOR LEAVING: JOB NUMBER 2 EMPLOYER S NAME: SUPERVISOR: STREET ADDRESS: CITY: STATE: ZIP: DATES EMPLOYED FROM: TO: SALARY: DUTIES: PHONE NUMBER: FAX NUMBER: YOUR JOB TITLE: REASON FOR LEAVING: JOB NUMBER 3 EMPLOYER S NAME: SUPERVISOR: STREET ADDRESS: CITY: STATE: ZIP: DATES EMPLOYED FROM: TO: SALARY: DUTIES: PHONE NUMBER: FAX NUMBER: YOUR JOB TITLE: REASON FOR LEAVING: SDC Employment Application REV 04/30/15 Page 4

5 Spring Dell Center, Inc. Employment Application EDUCATION/TRAINING HISTORY List high school, colleges, military, trade, business or other schools attended. Name and Location of School(s) (city and state) Graduate (Yes / No) Date of Graduation Type of Degree/ Certificate Received Course of Study SPECIALIZED SKILLS AND KNOWLEDGE Describe any specialized training you have received and list any skills or knowledge that is relevant to the position for which you are applying. Honors Received: REFERENCES List three, non-related, character references that can be reached during business hours. (Monday Friday, 8 a.m. 4 p.m.) Please complete this section in its entirety; applications cannot be processed without it. First & Last Names Telephone Number Address REQUIREMENTS UPON NOTIFICATION OF EMPLOYMENT 1. All applicants selected for employment are subject to drug testing prior to beginning employment. 2. All employees will be subject to random drug and alcohol testing. 3. New employees are required to bring proof of employment eligibility to their initial orientation. This includes the following: A. Driver s License B. Social Security Card or Birth Certificate Spring Dell Center, Inc. Employment Application SDC Employment Application REV 04/30/15 Page 5

6 EMPLOYMENT INTERESTS Please answer each of the following questions in complete sentences. ***PLEASE PRINT*** Please describe your career goals: Please tell us why you would like to work at Spring Dell Center: Please tell us something about yourself which might be relevant to Spring Dell Center and the position for which you are applying: Other interests: SDC Employment Application REV 04/30/15 Page 6

7 Employment Application READ CAREFULLY BEFORE SIGNING THIS APPLICATION I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all policies and procedures of the employer. UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. ANY EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $ This application for employment shall be considered active for a period of time not to exceed 1 year. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. Employment at Spring Dell Center, Inc. is at will. This means that Spring Dell Center, Inc. may terminate employment at any time, with or without notice and with or without cause. I authorize the release of any relevant information concerning my past employment to Spring Dell Center, Inc. Signature of Applicant Date SDC Employment Application REV 04/30/15 Page 7

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9 DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION] DISCLOSURE REGARDING BACKGROUND INVESTIGATION Spring Dell Center, Inc. ( the Company ) may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ( driving records ), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Pinkerton Consulting and Investigations, McCormick Road, Suite 120, Hunt Valley, MD, , or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Spring Dell Center, Inc. by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days. New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by Spring Dell Center, Inc., and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request. Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Pinkerton Consulting and Investigations, McCormick Road, Suite 120, Hunt Valley, MD, , another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. New York applicants or employees only: By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. Signature: Date: SDC Employment Application REV 04/30/15 Page 9

10 Background Information Form Last Name: First: Middle: Other Names used (including Maiden names): Social Security #*: Driver s License #: Present Address: Date of Birth*: State of Driver s License**: Phone: City/State/Zip: Years At This Address: Prior Address If Less Than 2 Yrs. At Current Address: Address: City/State/Zip: Previous Address: City/State/Zip: Previous Address: City/State/Zip: Previous Address: City/State/Zip: Former Employer: Position: Dates of Employment: ** If you will be requesting driving records, we recommend that you have this form notarized. *This information will be used for background screening purposes only and will not be used as hiring criteria. [Note: If you do business in Utah, you cannot ask for DOB, driver s license, or SSN until either a confidential offer of employment or at the time the background report will be run.] v.1 SDC Employment Application REV 04/30/15 Page 10

11 Spring Dell Center, Inc. Employment Application NOTICE TO APPLICANTS The federal government requires that an employer maintain records on the race, sex and ethnic group of its applicants. Uniform Guidelines on Employee Selection Procedures, 29 C.F.R et seq., 41 C.F.R el seq. (1978). In order to comply with these requirements, Spring Dell Center, Inc. requests that you supply the information sought below. The information is for record keeping purposes only. This questionnaire will be detached and kept separately from your application, and will not be used in consideration of your application for employment. Failure to provide this information will not jeopardize your opportunity for employment. PLEASE CHECK THE APPROPRIATE CLASSIFICATION: SEX: Male Female Race: White African American Asian/Pacific Islander American Indian/Alaskan Native Other Date of Birth: Position applying for: Month Day Year Date: How did you find out about this position? Please check one of the following: Maryland Independent Washington Post Pennysaver Sun Employee Referral In-House Posting Television Walk-In Word of Mouth Internet Website Other: SDC Employment Application REV 04/30/15 Page 11