Employment Application Form

Name:*

First NameLast Name

Phone Number:*

E-mail Address:

example@example.com

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload Resume:

Job Skills & Training

Describe your skills:

How many years of experience do you have working with children and/or families?

Training, Certifications and College Degrees

Are you currently or have you ever been employed by the State of Missouri?

NoIf yes, type dates of employment below:Other

Direct Supervisor's Name

Are you rehireable by the State of Missouri?

YesIf no, explain belowOther

References Please list three (3) references that are familiar with your work life.

Reference 1

Name:

First NameLast Name

Phone Number

Years Known:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference 2

Name:

First NameLast Name

Phone Number

Years Known:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference 3

Name

First NameLast Name

Phone Number

Years Known:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I authorize my employer, or potential employer, to investigate, obtain, compile, examine, copy or receive any records pertaining to my employment history; to obtain a copy of my college transcript(s); and understand completely and without reservation allow my employer to release and/or discuss any information about my employment history or college transcript(s) wit authorized personnel of the Department of Social Services. By authorization of the above, the applicant agrees to hold harmless any individual, partnership, corporation, educational institution, or agency, its officers, agents and employees, as well as the State of Missouri, from any liability for any damage whatsoever for issuing such information.The application contains no misrepresentation or falsifications and that the information given is true and complete to the best of my knowledge and belief, that, I, the applicant am aware that should an investigation at any time disclose any such misrepresentation or falsification as to a material fact, the application will be rejected or if selected, I, the applicant, may be dismissed by the employer.

Family Advocacy Solutions, LLC (FAS) is committed to maintaining a workplace that is free from discrimination and harassment in admission or access to, or treatment or employment in, its programs, services, activities and facilities. In accordance with law, FAS strictly prohibits discrimination and harassment against employees or others on the basis of race, color, religion, sex, national origin, ancestry, disability, age, genetic information or any other characteristic protected by law. FAS is an equal opportunity employer.

I certify that this application is true to the best of my knowledge and authorize Family Advocacy Solutions, LLC to contact any references as well as previous employers.

Signature*

Today's Date*

Date