Child, Family and Community Service's Inc.

Providing families and children a foundation to be successful.

Interested In *

Please select from: employment, volunteering or internship

Last Name *

First Name *

Home Address *

City *

State *

Zip *

Home Phone *

Position Interested In

Gender *

Drivers Lic. # *

DL# State *

DL# Exp Date *

Able To Perform *

Are you able to perform the essential functions of the position or opportunity for which you are applying (with or without reasonable accommodation)? This question is not designed to ellicit information about a disability. Please do not provide information about the existence of a disability, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law.

Ever Been Bonded *

NOTE: Answering "Yes" to the following question does not constitute an automatic bar to employment, internship or volunteering. Factors such as date of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account. (In answering these questions, do not include minor traffic infractions and convictions for which the record has been sealed or expunged, any convictions for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed, referrals to and participation in any pre-trial or post-trial diversion programs, and marijuana-related offenses that occurred over two years ago.)

Illegal Drugs *

Do you use illegal drugs?

Felony Conviction *

Have you ever been convicted of a felony?

Felony Conviction Detail

If you have been convicted of a felony, please provide details here.

Endangerment or Abuse *

Have you ever been convicted of child abuse or endangerment?

DL Suspended Revoked *

Has your drivers licence ever been suspended or revoked?

DL Suspended Revoked Detail

If your drivers license has ever been suspended or revoked, please provide details.

Able To Be Entrusted *

Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance and instruction of young people? If there are no such facts or circumstances relevant in your case, type "none" in this field.

Additional Information

Please provide any other relevant information you feel may be appropriate to disclose.

Grant Permissions *

I attest to the fact that the information that I have provided in this form is true, and if this application is not sufficient, I agree to provide the organization with any additional information or documentation requested in order to evaluate my request to become an employee of this entity.

Verify Information *

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.
I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

Email *

Attachments

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