Application - Syringa Family Partnership, LLC

Application for Employment
Date

MonthDayYear

Personal Information
Name*

FirstLast
Please list any other names you have worked under or used in the past
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone*
Email*

	Yes	No
Do you have a driver's license?
Do you have a vehicle in good running condition?
Are you able to perform the duties for the position you are applying for?
Do you have current CPR certification (that includes infant and children)?
Are you the parent, family member or friend of a client currently receiving services?
Are you able to travel up to 15 miles between Syringa locations and/or clients?

Have you ever been convicted of a felony?*

YesNo
If Yes, please explain:
Upon offer of employment, will you be able to provide verification of your legal right to work in the United States?*

YesNo
If No, please explain:

Position Applying For
Desired Position*
(BCBA®, RBT®, Intervention Professional, Intervention Specialist, Intervention Technician, Community Based Supports, Respite)
Position Status (select all that apply)*

Full TimePart TimeSummer onlyTemporary (less than 6 months)
Date Available to Start*
Maximum Number of Hours per Week*

Days/Times Available to work:*

	Day	8:00am-5:50pm	AM Only	PM Only
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Desired Salary*
Can you work overtime?*

YesNoOnly with notice

Education
High-School, College, Technical Training, Certification, etc. If there are not enough entry fields, email any additional history to employment@syringafp.com.
Name of School, College, etc.
City/State
Degree/Certification completed?

YesNo
If No, Why?
Type of Degree
Degree Major
Date of Degree/Certification
Name of School, College, etc.
City/State
Degree/Certification completed?

YesNo
If No, Why?
Type of Degree
Degree Major
Date of Degree/Certification
Name of School, College, etc.
City/State
Degree/Certification completed?

YesNo
If No, Why?
Type of Degree
Degree Major
Date of Degree/Certification

Employment History
Please include all employment for the last 7 years. If there are not enough entry fields, email any additional history to employment@syringafp.com. ALL employers will be contacted unless "Do Not Contact" is selected.
Current or Most Recent Employer*
Position Held*
Address*
Phone Number*
Manager*
Date Started*

MonthDayYear
Date Ended/Current*
Wage/Salary*
Reason for Leaving*
Do Not Contact
Employer
Position Held
Address
Phone Number
Manager
Date Started

MonthDayYear
Date Ended
Wage/Salary
Reason for Leaving
Do Not Contact
Employer
Position Held
Address
Phone Number
Manager
Date Started

MonthDayYear
Date Ended
Wage/Salary
Reason for Leaving
Do Not Contact
Employer
Position Held
Address
Phone Number
Manager
Date Started

MonthDayYear
Date Ended
Wage/Salary
Reason for Leaving
Do Not Contact

References
Please do not include relatives or former employers.
Reference 1*

Name

Occupation

Phone NumberYears Known

Address
Reference 2*

Name

Occupation

Phone NumberYears Known

Address
How did you hear about us?*

Our websiteIndeedOtherReferred
Other / Referred by:

Sign and Submit
Syringa Family Partnership, LLC. is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including but not limited to: age, gender, sexual orientation, color, race, national origin, religious persuasion, marital status, political beliefs, and/or disability that does not prohibit performance of essential job functions.

Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, alien registration card, etc within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination.

This application is valid for ninety (90) days. If you have not heard from us and would still wish to be considered for employment, it will be necessary for you to fill out a new application.

This Application for Employment is used to notify me that the nature and scope of investigation, if one is conducted, could include such general identification information as residence verification and, as applicable, information concerning my employment, education, general reputation, character, personal characteristics and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a reportwill be considered in evaluating my employment application or continued employment.
This Application for Employment is used to notify me that the nature and scope of investigation, if one is conducted, could include such general identification information as residence verification and, as applicable, information concerning my employment, education, general reputation, character, personal characteristics and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a reportwill be considered in evaluating my employment application or continued employment.

By signing below, I am acknowledging the following:
- I hereby authorize any and all listed references, former schools, former and/or current employers, and their agents and employees to answer all questions or release any information regarding my employment or educational experiences with them, and I hereby release any and all listed references, former schools, former and/or current employers, and their agents and employees from any liability and hold them harmless from any claim for releasing any truthful information within their knowledge and/or records.
- I authorize Syringa Family Partnership, LLC. to release to any person, firm, entity, or organizations with which I may seek employment, any truthful information concerning my work experience with Syringa Family Partnership, LLC., and I hereby release Syringa Family Partnership, LLC. and hold them harmless from any claim for releasing any truthful information within its knowledge and/or records.
- I understand and agree that, if hired, my employment is for no definite period and either I or Syringa Family Partnership, LLC. may terminate our relationship at will at any time, without notice or any reason, and that this employment application does not constitute an employment contract, and
- I certify that all the above information that I provided is true to the best of my ability. I understand that if I were to be hired by Syringa Family Partnership, LLC and had falsified any of my pre-employment records, it would result in termination of my employment.
Signature of Applicant*

Clear
Date*

MonthDayYear
Should be Empty:

Application for Employment