GCSS Employment Application

All Applicants Must Completely and Truthfully Answer All Questions in This Application

Gulf Coast Social Services (GCSS) is an equal employment opportunity employer dedicated to a policy of nondiscrimination in employment upon any basis, including race, color, creed, religion, sex, gender identity, sexual orientation, age, national origin, disability, genetic information, or military/veteran status.
Position(s) Applied For:*
Region*
Type of Work Desired:*

Full-timePart-timePRN
Date Available to Start Work:*

MonthDayYear
Date
List Days/Hours Available to Work:

Sunday: Sunday Start Time*to Sunday End Time*.
Monday: Monday Start Time*to Monday End Time* .
Tuesday: Tuesday Start Time*toTuesday End Time*  .
Wednesday: Wednesday Start Time*toWednesday End Time*   .
Thursday: Thursday Start Time*toThursday End Time*   .
Friday: Friday Start Time*to Friday End Time*   .
Saturday:Saturday Start Time*toSaturday End Time*   .

PERSONAL DATA
Name*
Email*
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.

EMPLOYMENT HISTORY
Please complete the following information about your past employment. This section must be completed in its entirety. List all jobs held in the past 15 years.
EMPLOYER 1
Company Name
Job Title/Duties
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date Employment Began

MonthDayYear
Date
Date Employment Ended

MonthDayYear
Date
Reason for Leaving
Supervisor
(include phone number if known)
Your Name When Employed
(if different from present name)
Would you like to add another employer?*

YesNo
EMPLOYER 2
Company Name
Job Title/Duties
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date Employment Began

MonthDayYear
Date
Date Employment Ended

MonthDayYear
Date
Reason for Leaving
Supervisor
(include phone number if known)
Your Name When Employed
(if different from present name)
Would you like to add another employer?*

YesNo
EMPLOYER 3
Company Name
Job Title/Duties
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date Employment Began

MonthDayYear
Date
Date Employment Ended

MonthDayYear
Date
Reason for Leaving
Supervisor
(include phone number if known)
Your Name When Employed
(if different from present name)
Would you like to add another employer?*

YesNo
EMPLOYER 4
Company Name
Job Title/Duties
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date Employment Began

MonthDayYear
Date
Date Employment Ended

MonthDayYear
Date
Reason for Leaving
Supervisor
(include phone number if known)
Your Name When Employed
(if different from present name)
Do you have additional employers that have not been added to this form?*

YesNo
Other Job-Related Experience:

ACKNOWLEDGEMENTS
By my signature and initials placed below, I promise that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment if discovered at a later date. I also understand that providing false information may, in some circumstances, constitute a criminal offense punishable by fine and/or imprisonment. I agree to immediately notify the Agency if I should be convicted of a felony, or any crime while my job application is pending or during my period of employment, if hired.

Type a label* initial
I authorize the investigation of all statements contained in this application (and accompanying resume, if any). I also authorize the Agency to contact any person, school, current employer (unless otherwise noted in this application form), past employer(s), listed references, and organizations named in this application form (and accompanying resume, if any) to provide the Agency with relevant information and opinion that may be useful to the Agency in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements. I also release the Agency from any and all liability in connection with the use and dissemination of such information.

Type a label* initial
If a contingent offer of employment is made, I consent to undergo a complete physical examination, including a drug-screening exam and x-rays, and I consent to the release of any and all medical information deemed necessary by the Agency to determine my ability to perform the essential functions of the job. I also understand that if such a contingent offer of employment is made and the Agency receives information that I am physically or mentally unable to perform the essential functions of that job, with or without reasonable accommodation, that contingent offer of employment may be retracted by the Agency without further obligation.

Type a label* initial
I understand that GCSS and state licensing require a criminal background check prior to employment, when periodically required by program guidelines, or at any time during my employment. If a check reveals that a person has been convicted of any of the offenses enumerated in the Louisiana Revised Statutes governing the Adult Protection Act or Child Protection Act, the Agency has the right not to offer the individual employment or to terminate employment pursuant to the act(s). I also understand that under the Fair Credit Reporting Act the results of the investigation will remain confidential and that if any inaccurate information is found to exist, I have the right to refute, correct, or otherwise clarify such information, within a reasonable period of time, and I will be provided with the name, address, and phone number of the agency that provided the information.

Type a label* initial
I authorize the Louisiana Department of Public Safety and Corrections, Office of State Police or their designee to conduct a thorough investigation of any record of past criminal activities prior to employment and at anytime during my employment. I understand the Louisiana State Police or their designee may, at their discretion, require further investigation (fingerprints) to determine if a criminal record exists. If at anytime during my employment, further investigation is required, I understand I would immediately be placed on (unpaid) administrative suspension pending the outcome of the criminal background check.

Type a label* initial
I understand that GCSS and state licensing require a motor vehicle records (MVR) check prior to employment, annually, and at any time during my employment as deemed necessary by the Agency. I hereby voluntarily authorize GCSS to conduct a search of my motor vehicle records prior to employment and at any time during my employment. I also release the Agency from any and all liability in connection with any and all MVR checks conducted.

Type a label* initial
I understand that federal and state regulations require employers, including GCSS, to enter employees’ information (name, date of birth, social security number), into federal and state exclusion databases prior to hire, and upon hire each month thereafter to ensure employees are eligible to provide services in a Medicaid program, as per Chapter 50 HCBS Provider Licensing Standards 5055. I also understand that I am not allowed to remain an employee of GCSS if I appear on any of these databases during my employment with the Agency. I hereby release GCSS, its officers, directors and employees from any claims of any type arising out of the disclosure and/or use of the information acquired through these databases.

Type a label* initial
I understand that when providing client services in a program that requires clocking in/out of an Electronic Visit Verification System, I will be required to use a suitable smart device capable of identifying GPS location for clocking in/out of my assigned shift. If a suitable device is not available at my designated worksite, I agree to use my personal smart device (cell phone) to clock-in/out and will be reimbursed for the additional data usage, as per the guidelines outlined in the Agency’s Cell Phone Usage Policy for this specific requirement.

Type a label* initial
I understand that if my employment is terminated by the Agency for dishonesty, breach of trust, or any criminal acts, the proper authorities may be notified and I may be criminally prosecuted. I also understand that, if hired, I may not hold other employment or engage in sales, investments or other activities that create a conflict of interest with my position with this Agency.

Type a label* initial
I understand that this application does not create a contract of employment. I understand and agree that, if hired, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD OF TIME, and may, regardless of the date of payment of my wages or salary, BE TERMINATED AT ANY TIME with or without "just cause." I also understand that requirements set out in this application are effective for any offer of employment and that verbal representations which purport to alter these terms and conditions are invalid and unenforceable.

Type a label* initial
I understand that the terms and conditions of my employment, if hired, are subject to change at the Agency’s discretion.

Type a label* initial
Date*

MonthDayYear
Date
Signature*

Clear

JOB REFERENCE RELEASE FORMS
1ST Employer's Name
1st Employer's Name
1st Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code
1st Employer's Phone
Please enter a valid phone number.
1st Employer's Supervisor/Contact Person
2ND Employer's Name
2nd Employer's Name
2nd Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code
2nd Employer's Phone
Please enter a valid phone number.
2nd Employer's Supervisor/Contact Person
3RD Employer's Name
3rd Employer's Name
3rd Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code
3rd Employer's Phone
Please enter a valid phone number.
3rd Employer's Supervisor/Contact Person
Applicant's Name*
Signature*

Clear
I authorize the above individual or company to furnish information concerning my past employment including dates of employment, position(s) held, salary, performance evaluations, reasons for separation/termination, and personality and character information. I agree to waive and release any claim I have against said company and/or its employees for releasing said information to Gulf Coast Social Services and to release Gulf Coast Social Services from any claims arising out of its use and/or consideration of such information.
Date*

MonthDayYear
Date
Should be Empty:

All Applicants Must Completely and Truthfully Answer All Questions in This Application

EMPLOYER 1

EMPLOYER 2

EMPLOYER 3

EMPLOYER 4

1ST Employer's Name

2ND Employer's Name

3RD Employer's Name