Family Services INC.

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	NAME & ADDRESS	MAJOR SUBJECT	DEGREE/DIPLOMA	DID YOU GRADUATE?
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	TYPE OF LICENSE, REGISRTY OR CERTIFICATION	ISSUING STATE OR ORGANIZATION	NUMBER	EXPIRATION DATE
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IT IS VERY IMPORTANT THAT YOU READ THIS SECTION CAREFULLY, AND THAT YOU FULLY UNDERSTAND IT BEFORE YOU SIGN THE EMPLOYMENT APPLICATION. THIS SECTION AFFECTS YOUR LEGAL RIGHTS.

I certify that to the best of my knowledge, the answers provided by me and the statements made by me in this application are correct and complete. I understand that any false information or intentional omission of information contained in the application will disqualify me from employment consideration or lead to my discharge if discovered after being hired. I consent to background checks which may include, but not be limited to: employment and personal references, education verification, motor vehicle check, DPW screening to determine any exclusion from participation in federal health care programs, FBI, child abuse history and criminal history check. I understand I will also be required to undergo a pre-employment physical exam and drug screening. Employment is contingent upon successful completion of these procedures. I agree to release former employers and others from liability that might arise from their disclosure about me. I understand that an offer of employment does not represent a contractual relationship, or definite term of employment. If hired, I will be an “at-will” employee, and my employment may be terminated by Family Services Incorporated or by me, at any time, with or without cause.

Family Services INC.

EMPLOYMENT HISTORY