/ Application For Employment

Le’Chris, Inc. et al is anEqualOpportunityEmployerandfullysubscribeto theprinciplesof EqualEmploymentOpportunity.Applicantsand/oremployeesare consideredforhire,promotionandjobstatus, withoutregardtorace,color,religion,creed,sex,maritalstatus, nationalorigin,age,physicalormental disability.

Name: / Date of Application:
Last First Middle Maiden Name
Address:
Street City State Zip Code County
Telephone Number: / How Long at Current Address:

Other Counties/States of Residence in the past 5 years:

County / State / Dates

1. GENERAL INFORMATION:

Are you able toperform the essential job functions ofthe position forwhich you are applying with or without reasonable accommodation(s)? Yes No If no, please explain (use additional sheet(s) if necessary):

2. EDUCATION & TRAINING:

List highest gradecompleted for each: High School: College: Masters: Doctorate:

Name & Address ofSchool / Major
Course studied / Graduated(Y orN) or degree
LastHighSchoolAttended/Address:
College or University/Address:
College or University/Address Other School (Technical, Vocational, Graduate, etc.)/Address:
List anyscholarships, academic honors, awards or special achievements:
3. SKILLSPlease list any, certifications, licenses,skills you have appropriate for the position you are applying for:
Ifrequired, will you work? / Rotating Shifts: YES NO / Saturdays: YES NO
Overtime: YES NO / Sundays: YES NO
Position Applying for (be specific): / Date you could start:
Salary Requirements: $ ______/ per hour per year
Application for Employment / Page 1 of 4 / Last Update: 5.9.2018
/ Application For Employment

EMPLOYMENT HISTORYstarting with your PRESENT or MOST RECENT EMPLOYER list in consecutive order ALL EMPLOYMENTfor at least the past FOUR employers.If currently employed, may we contact your employer Yes No

Company / Phone: / Salary
Begin/End / Employed
From To
mo/yr mo/yr
Address:
Name & Title of Supervisor / Title of Your Position / Reason for Leaving:
LISTJOBSHELD,DUTIESPERFORMED,SKILLSUSED,PROMOTIONSWHILEEMPLOYEDATTHISCOMPANY:
Company / Phone: / Salary
Begin/End / Employed
From To
mo/yr mo/yr
Address:
Name & Title of Supervisor / Title of Your Position / Reason for Leaving:
LISTJOBSHELD,DUTIESPERFORMED,SKILLSUSED,PROMOTIONSWHILEEMPLOYEDATTHISCOMPANY:
Company / Phone: / Salary
Begin/End / Employed
From To
mo/yr mo/yr
Address:
Name & Title of Supervisor / Title of Your Position / Reason for Leaving:
LISTJOBSHELD,DUTIESPERFORMED,SKILLSUSED,PROMOTIONSWHILEEMPLOYEDATTHISCOMPANY:
Company / Phone: / Salary
Begin/End / Employed
From To
mo/yr mo/yr
Address:
Name & Title of Supervisor / Title of Your Position / Reason for Leaving:
LISTJOBSHELD,DUTIESPERFORMED,SKILLSUSED,PROMOTIONSWHILEEMPLOYEDATTHISCOMPANY:

READCAREFULLY: I certify that the information contained in this application is correct to the best of my knowledge and understand that any misstatement or omission of information may result in denial of employment or discharge. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

Applicant Signature: ______Date: ______

Signature of Interviewer: ______Date: ______

Application for Employment / Page 1 of 4 / Last Update: 5.9.2018
/ Application For Employment - Questionnaire

Name: ______Date: ______

Please answer the following questions:

  1. Why are you interested in employment with us?
  1. How did you hear about this position?
  1. Describe your feelings about people with mental illness and/or intellectual developmental disabilities.
  1. Describe your experience (personally and professionally) with people who have a mental illness, and/or intellectual developmental disability.

Application for Employment - questionnaire / Page 1 of 4 / Last Update: 7.15..2015
/ Application For Employment:
Pre-employment Disclosure and Authorization

By signing my name below, I have been given an opportunity to review each of the following statements and authorize any inquiry into the statements made in this application as may be necessary in reaching an employment decision.

I understand that any false or misleading information given on this applicationor during a pre-employment interview, including a failure to disclose requested information, may result in my discharge.

I understand that upon offer of employment I must consent to having an alcohol drug screening testas a condition of employment and that the outcome of this test and/or any subsequent investigations/inquiries may result in my discharge.

I understand that any accident/incident will be considered just cause for a drug test.

I understand that any employment relationship with Le’Chris Inc., et al is “at will”; meaning the employee may resign at any time and the employer may discharge the employee at any time with or without cause. I further understand that this “at will” employment relationship may not be changed.

I understand that my employment is contingent upon all background checks meeting Le’Chris standards.

I AGREE TO HAVE MY CRIMINAL BACKGROUND CHECKED AND(check one):

SWEAR AND AFFIRM TO NEVER HAVING BEEN CONVICTED OF A CRIME OR

HAVE BEEN CONVICTED OF A CRIMEIN THE PAST, BUT WOULD LIKE TO PROVIDE EXPLANATION AS TO THE CIRCUMSTANCES for IMPENDING CONSIDERATION OF EMPLOYMENT (use additional sheet(s) if necessary).

only have criminal convictions due to minor traffic violations AND/OR

CURRENTLY AWAITING TRIAL FOR A CRIMINAL OFFENSE? PLEASE PROVIDE EXPLANATION AS TO THE CIRCUMSTANCES for IMPENDING CONSIDERATION OF EMPLOYMENT (use additional sheet(s) if necessary).

Note: A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position for which you are applying.

______

Printed Name

______

Signature Date

Application for Employment –disclosure & authorization / Page 1 of 4 / Last Update:5.9.2018