Employment ApplicationInterested in joining our team? Fill out the application below. APPLICANT INFORMATION Name * First Name Last Name Application Date * MM DD YYYY What position(s) are you applying for? * Peer Support Specialist Qualified Professional Office Professional Independent Contractor (Clinical) Independent Contractor (Non-Clinical) Other Applied/Employed Before? Yes No If "Yes" to Applied/Employed Before, please indicate the year of previous application/employment? Year of previous application or employment If Employed Before, please indicate the Reason for Leaving: Reason for Leaving Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you able to perform the essential functions of the position for which you are applying either with or without reasonable accommodations? * Yes No Are you applying for: * FT PT PRN Other Are you at least 18 years old? * Yes No Date available to start? MM DD YYYY Work Availability Schedule (Please select all times available to work. Check all that apply): First Shift Second Shift Overnight Weekends All Shifts Foreign Languages Spoken/Written Indicate any foreign languages here Do you have reliable transportation? * Yes No Can you submit verification of your legal right to work in the United States? Yes No EMPLOYMENT HISTORY Please start with your most recent job. Account for all time including periods of unemployment. Please list and explain all periods of unemployment during the last five (5) years. Have you ever been terminated or asked to resign from any job? Yes No If "Yes" to previous question, please explain the circumstances: CRIMINIAL HISTORY Please exclude any misdemeanor conviction of possession of marijuana occurring more than two years ago, any referral to pre-trial or post-trial diversion program, or any misdemeanor conviction for which probation was completed and the case was dismissed and any convictions that have been judicially ordered sealed, expunged or statutorily eradicated. Have you ever been convicted of a criminal offense other than a minor traffic violation? * Yes No Explain fully each conviction (include dates) and identify the crime, the state, and county of the court in which you were convicted. Criminal History Explanation/Disclosure DISCLOSURE I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals contacted, to provide any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information as well as from the use or disclosure of such information by the employing organization or any of its agents, employees or representatives. I understand that any misrepresentation or falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my termination from employment. In consideration of my employment, I agree to conform to the rules and standards of the organization. I further agree that my employment can be terminated at will, or my compensation altered at will by the organization, with or without cause, and with or without notice, at any time, either at my option or at the option of the employer. I understand that no employee or representative of this organization, other than its Director, has the authority to enter into an agreement for employment for any specified period of time, or to make any express or implied agreement contrary to the foregoing. Further, the Director of this organization may not alter the at-will nature of the employment relationship or enter into any employment agreement for a specified time unless the Director and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this shall constitute a final and fully binding integrated agreement with respect to the at-will nature of my employment relationship and that there are no oral or collateral agreements regarding this issue. Except as required in the performance of my duties, I understand and agree that I will not at any time during or after my employment use or disseminate any confidential information or any other information of a secret, proprietary, or generally undisclosed nature relating to this employer, or its programs, clients, employees, plans or procedures (all of which constitute trade secrets). I agree to deliver to this employer/organization any copies of confidential information, or other company property, upon termination of the employment relationship or at any time upon request. I also agree not to solicit employees or clients of this employer/organization either during or for one year after employment to leave the organization and commence work with another company. I also understand that all offers of employment are conditioned on receipt of satisfactory responses to reference requests and the provision of satisfactory proof of an applicant’s identity and legal authority to work in the United States. I certify that I have received separate written notification disclosures and authorization request so that this employer/organization may obtain a consumer report on me. This report may be used in connection with my application for employment and for other employment-related purposes. I HAVE CAREFULLY READ AND AGREE TO THE ABOVE. Sign * First Name Last Name Thank you for applying to Carolina Community Group. We will review your application and reach out if we believe it’s a good fit.
