Employment Application 21

APPLICATION FOR EMPLOYMENT
We appreciate your interest in a prospective employment opportunity with Positive Growth, Inc. Positive Growth relies upon the accuracy of the information contained in the employment application, as well as the accuracy of other data presented throughout the hiring process and employment. Any misrepresentations, falsifications, or material omissions in any of this information or data may result in Positive Growth's exclusion of your Application from further consideration for employment or, if hired, termination of employment. Our Company is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, gender, sexual orientation, age, religion, national origin, veteran status, or any disability as provided in the Americans With Disabilities Act.

This Application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered completely and accurately as no action can be taken on this Application until all questions have been answered. Please print, in ink, or type answers to all questions. If you have a current resume or curriculum vitae, please do submit it for review as well. While you may reference your resume for some items on this Application, please make sure to provide answers and detailed information to all of the items on this Application.

The following are items will be required from you as part of the application process: verification of educational attainment and/or specialized training; copies and verifications for certifications and/or licensure; verification of previous employment and references; a motor vehicle driving record for most positions; proof of automobile insurance coverage for most positions; and, proof of citizenship or authorization to work in the United States. A criminal justice background record check supported by required fingerprinting will be conducted on all new hires through the State of Georgia Crime Information Center (GCIC) and the FBI/GBI. All applicants will be processed through the Georgia Applicant Processing Services (GAPS) and checked against the Georgia Bureau of Investigation Case Search website. Applicants for positions in services supported by federal healthcare programs will be cross-checked against the federal debarment database. Applicants for positions in certain children's programs will have to undergo a finger print check through the Department of Human Services (DHS
PERSONAL DATA:
TODAY'S DATE

Month Day Year
Date
Name

Last Name First Name Middle Name
Present Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Work Phone
Email Address
example@example.com
1) Alternative Contact Number
Alternative Contact Number
Are you 18 or over?

YES NO
Social Security #
Are you a citizen of the U.S., or do you have the legal right to be employed in the U.S.

YES NO
Excluding minor traffic violations, have you ever been convicted of any crime, have any pending charges, received a not criminally responsible disposition, or pled "no contest" to any crime including DWI/DUI?

YES NO
If yes, state the offense, location, date, and disposition:
(NOTE: A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM EMPLOYMENT, BUT FAILURE TO ANSWER THIS QUESTION COULD LEAD TO YOUR APPLICATION NOT BEING CONSIDERED)
REQUIRED BACKGROUND CHECKS:

REFERENCES:
Three professional references are required for all applicants. Authorization for the reference to release information and contact information must be provided on copies of the Positive Growth, Inc. Reference Check Form, a copy of which can be obtained from: Click here: Reference Form
Reference #1
Reference Company / Agency Name:
Point of Contact
Point of Contact's Position
Point of Contact's Phone No.
Please enter a valid phone number.
Email
example@example.com
Date

Month Day Year
Date
Reference #2
Reference Company / Agency Name:
Point of Contact
Point of Contact's Position
Point of Contact's Phone No.
Please enter a valid phone number.
Email
example@example.com
Date

Month Day Year
Date
Reference #3
Reference Company / Agency Name:
Point of Contact
Point of Contact's Position
Point of Contact's Phone No.
Please enter a valid phone number.
Email
example@example.com
Date

Month Day Year
Date
Three professional references are required for all applicants. Authorization for the reference to release information and contact information must be provided on copies of the Positive Growth, Inc. Reference Check Form, a copy of which can be obtained from: Click here: Reference Form
ADDITIONAL SPACE: (For extended comments, volunteer work, work history, etc.)
AFFIDAVIT:
I HEREBY CERTIFY THAT my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading, or otherwise incorrect statements made on this application form, other documentation, or during an interview may be grounds for my immediate discharge.

I HEREBY CERTIFY THAT I have never been convicted of and it has never been shown by credible evidence, e.g., a court or jury, a department investigation or other reliable evidence that I have sexually assaulted, abused, neglected or deprived a child, or adult or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of the Application;"

I HEREBY AUTHORIZE POSITIVE GROWTH, INC. to contact any company or individual it deems appropriate to investigate my employment history, character, and qualifications. I give my full consent to current and previous employers' revealing any information they may wish as a result of this investigation. In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy, or any other reason because of their statements.
I AGREE THAT if I am employed, I will abide by all the policies, procedures, rules, and regulations of POSITIVE GROWTH, INC. I understand that the taking of a drug and alcohol test, when given pursuant to company policy, is a condition of continued employment, and refusal to take such tests when asked will be grounds for my immediate termination. In the absence of a written employment agreement, I understand that employment with POSITIVE GROWTH, INC. Program is 'at will said, in such case, may be terminated by the Company at any time for any reason or no reason at all, with or without prior notice. Some jobs at POSITIVE GROWTH, INC. may be eligible for the establishment of a formal employment agreement or contract. No one at POSITIVE GROWTH, INC. has the authority to modify the "at-will" employment relationship or enter into any employment contract with an employee except the Chief Executive Director or another designee of the Board of Directors, and then only by written agreement.

I UNDERSTAND THAT if I am employed, a criminal justice background record check supported by required fingerprinting will be conducted on all new hires through the State of Georgia Crime Information Center (GCIC) and the FBI/GBI. All applicants will be processed through the Georgia Applicant Processing Services (GAPS) and checked against the Georgia Bureau of Investigation Case Search website. I further understand that applicants for positions in services supported by federal healthcare programs will be cross-checked against the federal debarment database. Applicants for positions in certain children's programs will have to undergo a child protective services background check through the Department of Human Services. I hereby grant POSITIVE GROWTH, INC permission, to conduct all necessary background investigations. I also understand that UNDER GEORGIA LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100.00.

I UNDERSTAND THAT, if employed, a confidentiality letter must be signed and forwarded to Positive Growth, Inc." I UNDERSTAND THAT if employed, that Non-Violence Crisis Prevention Training, CPR, and First Aid are prerequisites for employment with Positive Growth, Inc. and must be updated annually by a certified instructor and/or licensed physician. You have thirty days from the date of your signature to supply proof of certification.
APPLICANT SIGNATURE

Clear
DATE

Month Day Year
Date
WITNESS SIGNATURE

Clear
DATE

Month Day Year
Date
GUIDE USE ONLY
INTERVIEWED BY:
INTERVIEWER'S REMARKS:

Name
DOB
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Alternate Number
In Case of an emergency, please contact:
1st Name
Phone Number
Address

Address

Street Address Line 2

City State

Zip
Relationship to Client
2nd Name
Phone Number
Address

Address

Street Address Line 2

City State

Zip
Relationship to Client
List any medical conditions you would like us to be aware of
List any medical assistive devices you use (if applicable)
List any medications you are taking
List any allergies, including allergies to medications
Name of Family Physician
Phone Number
Name of Dentist
Phone Number
Employee's Signature

Clear
DATE

Month Day Year
Date
Strict confidentiality will be maintained. This form will be updated on an annual basis.
Should be Empty: