NW Inc Form

NW inc

NETWORK, INC.,

15 Welles Rd.,
Vernon CT 06066
Phone: 860-742-1313
Fax: 860-512-0373
“Looking Past Disability Seeing Potential” www.networkhumanservices.org

EMPLOYMENT APPLICATION

Network, Inc. does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex, marital status, sexual orientation, gender identity or expression, ancestry, disability with or without reasonable accommodation, status as a disabled veteran or Vietnam Era veteran or on the basis of age. You will be required to produce documentation/identification that will determine your legal right to be employed in the United States.
PERSONAL INFORMATION
Social Security #
Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Are you at least 18 years of age?
- Yes
- No
Are you a citizen of the USA?*
- Yes
- No
If “NO”, under what authority will you be working in the USA?_
Have you ever been employed here before?*
- Yes
- No
If yes, when?
What position?*
Have you ever applied for a job here before?*
- Yes
- No
If yes, when?
How were you referred to Network, Inc.?*
Do you have any relatives working for us?*
- Yes
- No
If yes, who?
REFERENCES
Please provide the following information for 2 references.
Reference #1 Name*
Reference #1 Phone*
Reference #2 Name*
Reference #2 Phone*
EDUCATION, LICENSES, AND CERTIFICATIONS
Highest Level of Education Completed:*
Name of School:*
List any professional licenses and/or certifications:*
Check off current trainings:*
- FA
- CPR
- PMT
- DDS Med. Certification
- None
WHAT POSITION ARE YOU APPLYING FOR?*
- Full Time
- Part Time
- Relief
- Temp
WHAT JOB TITLE ARE YOU APPLYING FOR?*
- Direct Support Staff
- LPN
- RN
- Residential Manager
Salary Requirements*
What shifts are you available to work?*
- 1st Shift
- 2nd Shift
- 3rd Shift
- Weekends
What days are you available to work?*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
What towns are you willing to work?*
- Select All
- Bloomfield
- Manchester
- Tolland
- Coventry
- Ellington
- Columbia
- Hebron
- Marlborough
- Willimantic
- Andover
- Ashford
- Dayville
- Danielson
- Putnam
- Vernon
- South Windsor
TELL US ABOUT YOUR WORK EXPERIENCE
1. Name of Current or Most Recent Employer*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Job Title*
Supervisor's Name*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Job Duties*
Reason For Leaving*
2. Employer*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Job Title*
Supervisor's Name*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Job Duties*
Reason For Leaving*
Please answer the following questions.
Your answers will be held in strict confidence, except as needed to process your application.
Are there any criminal charges currently pending against you?*
- Yes
- No
If yes, when?*
Where?*
Describe*
Do you currently use illegal drugs?*
- Yes
- No
Do you possess a valid driver’s license?*
- Yes
- No
Has your driver’s license ever been suspended or revoked in any state?*
- Yes
- No
If yes, when?*
Where?*
Describe*
Are you comfortable assisting with hygiene needs?*
- Yes
- No
Are you physically able to lift, transfer, and support individuals?*
- Yes
- No
Exhibit B

Network, Inc. Disclosure and Authorization for the Release of Information Network, Inc. (hereinafter, “THE EMPLOYER”) will use Research Services, LLC, a consumer reporting agency (CRA) as an agent to perform its employment related background check. The agency will provide a written report of its findings to THE EMPLOYER. I understand my prospective employer intends to utilize the background check for employment purposes only, and shall not disclose such information to any other party.
Above named CRA, Research Services, LLC. may utilize various sources of information including but not limited to: credit reporting agencies, workers compensation records including any and all injuries in compliance with the Federal Americans with Disabilities Act, Department of Motor Vehicle driving records, criminal records, current and former employers, military records, education records, professional and personal references. I request, authorize and consent to the release and disclosure of any and all information including but not limited to the above to THE EMPLOYER, and Research Services, LLC, a CRA.
I request, authorize and consent to the procurement of an Investigative Consumer Report and understand that they may contain information about my background, mode of living, character, work history, personal characteristics, professional standing and general reputation. This authorization in original or copy form shall be valid from the date signed and remain in effect for the duration of employment. According to the Fair Credit Reporting Act, I will be notified by THE EMPLOYER if employment is denied because of information obtained from a CRA. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to THE EMPLOYER. I further understand that when requesting a copy of the report, proper identification will be required and I may direct my request to Research Services, LLC 124 Simsbury Road Building One, Avon, CT., 06001. California residents will automatically receive a copy of the report within 7 days of delivery to the employer. I understand that residents of all other states will automatically receive a copy of the report if an adverse action is taken regarding the employment application, or upon request as outlined above.
********PLEASE FILL OUT THIS FORM COMPLETELY********
Name*
First Last
List ALL other first & last names ever used:*
SSN*
Date of birth*
Date Format: MM slash DD slash YYYY
Driver's License #*
Driver's License #*
State Issued:*
Expires*
Date Format: MM slash DD slash YYYY
CURRENT Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long at address?*
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long at address?
Last School/College Attended*
State*
Last Year Attended*
Did you graduate?*
If you graduated, check one*
- GED
- Diploma
- Degree
Registered and/or Graduated under what name?*
First Last
Signature*
Network, Inc. will conduct a background check. The results of the background investigation may be returned to Network, Inc. after an offer of employment is extended by Network, Inc. and accepted by you. If this background check reveals any information which is contrary to the answers you provided in this employment application, Network, Inc. reserves the right to (1) refuse an offer of employment; or (2) terminate your employment.
Network, Inc. will conduct pre-employment drug tests for all applicants selected for employment. An applicant whose results of drug testing do not indicate illegal drug usage may be considered as eligible for employment. An applicant whose results of drug testing indicate that the applicant has used an illegal drug(s) shall be disqualified from employment. The following criteria shall be deemed as refused testing and the applicant shall be disqualified for employment: (1) applicant who expressly declines drug testing or engages in conduct that clearly obstructs the testing process, (2) applicant who fails to appear for drug testing after proper notification, (3) applicant who fails to provide adequate urine for testing without a valid medical reason.
I understand that as part of the education and past employment verification Network, Inc. may contact any of my educational institutes and previous employers for information regarding my relationship with them. I hereby authorize them to disclose any relevant information to Network, Inc. as may be necessary to process my application for employment. I hereby further agree that a copy of this authorization shall be as effective and shall serve the same purpose as the original.
I understand that if an offer of employment is made to me, it may be conditioned upon a satisfactory health evaluation by a medical doctor including the TINE test.
In the event of my employment with Network, Inc. I will comply with all rules and regulations and set forth in Network, Inc.’s Policy & Procedure book or other communications distributed to all employees. Employment at Network, Inc. is voluntarily entered into for no stated term or period of time. I understand that if I am hired, my employment will be “at will” and may be terminated at any time. I further understand that the “at will” nature of my employment cannot be changed except by a formal written contract signed by the Executive Director of Network, Inc.
I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing that would, if disclosed, adversely affect this application. Making false statements on this application would be grounds for termination.
I understand that an investigative background inquiry is to be made of myself including, but not limited to, criminal history, driving history, employment history, sex offender bureau check, DDS Work Registry, HHS/OIG/GSA (welfare fraud) and other reports. I hereby give my permission for Network, Inc. to request this information.
I hereby authorize, without reservation, any party or agency contacted to release full and complete information as may be requested by Network, Inc. I waive any right to view this information, and release Network, Inc. from all liability for reporting any information requested by Network, Inc. To aid in the proper identification of my file or records, I am providing the following information, as well as any other information that may be required at a later date.
Name*
First Last
SS#*
Date of Birth*
Date Format: MM slash DD slash YYYY
Driver's License*
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I hereby acknowledge that I have read the above statements and understand them.
Printed name of applicant*
Date*
Date Format: MM slash DD slash YYYY
Signature of Applicant*
Date*
Date Format: MM slash DD slash YYYY
EEO Applicant Data Form (Optional) Important information for all applicants: To enable Network to meet government reporting regulations and to maintain an Affirmative Action Plan, applicants are requested to complete this personal data sheet. Information will be used for government reporting purposes and will be detached and kept separate from your job application. This information will not be used as selection criteria and will be treated as personal and confidential. Your decision or refusal to provide the requested information will not subject you to any adverse treatment. Your voluntary cooperation will be appreciated.
SEX
- Female
- Male
RACE/ETHNIC CATEGORY: (Due to Government reporting constraints, please check the most appropriate category)
- White
- Native American or Alaskan Native
- Asian or Pacific Islander
- Black
- Hispanic
- Other
I am a qualified handicapped individual who (1) has a physical or mental impairment which substantially limits one or more major life activities, (2) has a record of such impairment, or (3) is regarded as having such impairment and (4) is capable (qualified) of performing a particular job with reasonable accommodation to my handicap.
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NW inc

NETWORK, INC.,

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

REFERENCES

EDUCATION, LICENSES, AND CERTIFICATIONS

TELL US ABOUT YOUR WORK EXPERIENCE

Please answer the following questions.

Exhibit B

I hereby acknowledge that I have read the above statements and understand them.