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*   .
- Name*
- Email*
  example@example.com
- Current Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Mobile Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Secondary Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Please read carefully.
  
  All applicants must answer all questions in this section.
- Have you ever applied for a job with this Agency in the past?*
  
  YesNo
- If yes, please give the date of application and the position for which you applied. State your name at that time, if different from your present name.*
- Have you ever been employed by this Agency in the past or are you currently working in another program or another region within the Agency?*
  
  YesNo
- If yes, please give dates of employment, position(s) held, and state your name, while employed, if different from your present name.*
- If hired, will you be able to work during the normal days and hours required for the position(s) for which you are applying?*
  
  YesNo
- If no, please explain:*
- Do you work for another employer? Note: Under state licensing regulations, if you are providing direct care services, you cannot work more than 16 hours in a 24-hour period for GCSS or in combination with another HCBS Provider Agency. The 24-hour period begins at the time of the first shift worked that day.*
  
  YesNo
- If yes, please provide the name(s) of employer(s) and current schedule(s). *
- Are you related to anyone currently employed with our Agency?*
  
  YesNo
- If yes, please list name(s) and relationship(s):*
- Are you related to anyone currently served by our Agency?*
  
  YesNo
- If yes, please list name(s) and relationship(s):*
- Are you the legal guardian, married to, engaged to, dating, living with, curator or undercurator, tutor or undertutor, or the authority of representation of anyonecurrently served by our Agency? Note: Under contract/licensing regulations, certain personal relationships areprohibited from working with Agency clients.*
  
  YesNo
- If yes, please list name(s) and relationship(s):*
- If hired, can you furnish proof that you are 18 years of age, or if under 18, do you have a permit to work?*
  
  YesNo
- If no, please explain:*
- If hired, can you furnish proof that you are eligible to work in the United States? If unsure of the documents needed to prove eligibility to work in the U.S., we will explain the requirements.*
  
  YesNo
- If no, please explain:*
- Under licensing requirements for certain programs, do you have access to a smartphone/device during hours of employment?*
  
  YesNo
- Do you have any experience from your prior employment or military service that would be relevant to the job(s) for which you are applying?*
  
  YesNo
- If yes, please explain:*
- Are you charged with an unresolved criminal charge (have you been charged with a crime that has not yet resulted in a plea of guilty, court trial, or a dropping of the charge)? Note: A yes answer will not automatically disqualify you from employment.*
  
  YesNo
- If yes or unsure, please explain fully:*
- During the past five years, have you ever been denied a driver's license or convicted of a moving traffic offense, including, but notlimited to, driving while intoxicated or reckless driving?*
  
  YesNo
- If yes, please explain:*
- Have you ever been convicted, pled guilty, or pled "no contest" to any criminal offense? If you were charged, but the charges were dropped or you were acquitted, answer "No." Note: A yes answer does not automatically disqualify you from employment since the nature of the offense(s) and date(s) will be considered. However, proof of the date(s) and nature of the offense(s) will be required for employment.*
  
  YesNo
- If you answer yes, list all offenses, including the date(s)and nature of the offense(s).*
- Have you ever been excluded from providing Medicaid Services by the Office of Inspector General?*
  
  YesNo
- If yes, please explain:*
- Have any charges against you been substantiated by a Protective Services Agency for alleged Abuse, Neglect, Exploitation, or Extortion of an individual?*
  
  YesNo
- If yes, please explain:*
- Acknowledgement
  
  I understand that any falsification of this application or the information provided herein is grounds for rejection of an application and/or termination of employment if hired. I promise that the information I have provided is truthful and accurate. I also understand that providing false information may, in some circumstances, constitute a criminal offense punishable by fine and/or imprisonment.
- Date*
  
  MonthDayYear
  Date
- Signature*
- Are you willing and able to travel to out-of-town locations within the state, including occasional overnight trips?*
  
  YesNo
- Do you have a valid driver's license per Louisiana law, access to a reliable vehicle with proof of insurance, a Louisiana registration, and a current inspection sticker?(Active military and full-time out-of-state students may be licensed and insured in their state of residence.)*
  
  YesNo
- If no, are you active military/military dependent or a full-time out-of-state student?*
  
  YesNo
- In positions that require working directly with our clients, are you able to transport an assigned client in a vehicle you provide?*
  
  YesNo
- If the answer to the preceding question is yes, is this vehicle able to be operated at an internal temperature that does not compromise the health, safety, or needs of the client?*
  
  YesNo
- If offered a position, are you willing to undergo a physical examination by a physician to prove you are physically able to perform the essential functions of the job for which you have applied?*
  
  YesNo
- If no, please explain:*
- Do you know of any reasons that might make it difficult for the Agency to obtain a surety bond insuring your honesty?*
  
  YesNo
- If yes, please explain:*
- Direct Client Care Positions Only, please answer the following question.
  
  Question(s) Where Job Involves Physical Labor:
- This position requires lifting, turning, repositioning, providing stability with ambulation with assigned clients, as well as providing assistance with personal care and hygiene activities. Are you able to perform these functions?
  
  YesNo
- If the answer to the preceding question is yes, do you agree to take a test, at your own risk of injury, to prove your ability? And do you agree that the test will be conducted without any legal liability upon the Agency for any injuries which might result?
  
  YesNo
- Professional Positions Only, please answer the following question.
- Do you have all the licenses and professional certifications listed in the job announcement, job advertisement, or job description, or that are necessary to perform the job(s) for which you are applying?
  
  YesNo
- If no, please explain:
- Professional Positions Only, please answer the following question.
- List the business machines and computer programs you can operate.
- 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:
- What was the name and location of your high school?
  Name, Location
- Did you Graduate High School?*
  
  YesNo
- If no, what was the highest grade you successfully completed?*
- Do you have any technical, vocational, business or military training?
  
  YesNo
- Name of School: *
  Did you graduate? *
  Degree/Diploma/Certificate Earned:   *
  Year Graduated:   *
  Major Course of Study:   *
- Did you attend a College or University?
  
  YesNo
- Name of School: *
  Did you graduate? *
  Degree Earned:*
  Year Graduated:   *
  Major Course of Study:   *
- Did you attend Graduate School?
  
  YesNo
- Name of School: *
  Did you graduate? *
  Degree/Diploma Earned:   *
  Year Graduated:   *
  Major Course of Study:   *
- Have you completed a Professional Seminar?
  
  YesNo
- Name of Organization: *
  Did you complete the seminar? *
  Certificate Earned:   *
  Year Earned:   *
  Topic of Study:   *
- 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*
- 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.Format: (000) 000-0000.
- 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.Format: (000) 000-0000.
- 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.Format: (000) 000-0000.
- 3rd Employer's Supervisor/Contact Person
- Applicant's Name*
- Signature*
- 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