PALS Employment Form
Full Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
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Gereral Information
Position Applied For
*
Receptionist
Direct Support
Case Manager
Other
Available to Work
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Part-Time
Full-Time
Temporary
Date Available to Start Work
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-
Month
-
Day
Year
Date
Shift Desired
*
Day
Night
Swing
All
If you are under the age of 18, can you provide a work permit if offered a job?
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Yes
No
If you are not a US citizen, do you have the right to work in the US?
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Yes
No
Have you been convicted of a felony within the last seven years? NOTE: Pleas exclude convictions that have been sealed, expunged, or legally eradicated. A conviction is not an automatic bar to employment. Each case will be considered on its own merits.
*
Yes
No
If yes, please identify the charge, the court, the date of the conviction, and the disposition of the case.
Have you ever applied for a position with or worked for the Company before?
*
Yes
No
If yes, when did you start?
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Month
-
Day
Year
Date
If yes, when did it end?
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Month
-
Day
Year
Date
Have you been vaccinated for COVID-19? Proof of vaccination may be required.
*
Yes
No
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Education
What if the name and address of the high school you have graduated from? If this does not apply, type N/A.
*
Did you graduate from high school?
*
What is the name and address of the college or university you have graduated from? If this does not apply, type N/A.
*
If so, what is your major?
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If so, how many years did you complete the degree?
*
Did you graduate?
*
Have you attended another educational institution? If so, please state the name and address, the major or certification, number of years, and whether you have graduated.
Language Proficiency
What language(s) can you speak proficiently?
*
English
Spanish
Other
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Employment History
Job #1
Name of Employer
Address
Phone Number
Position
Description of Duties
Reason for Leaving
Name of Supervisor
Month and Year you started job
Month and year you ended job
Starting Wage
Ending Wage
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Employment History
Job #2
Name of Employer
Address
Phone Number
Position
Name of Supervisor
Description of Duties
Reason for Leaving
Month and Year you started
Month and year you finished
Starting wage
Final Wage
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Employment History (continued)
Identify and explain all the periods of unemployment in excess of one month during the past 10 years. What was the period of unemployment?
What was the reason for unemployment?
To assist us check records and to verify prior employment and education, please indicate whether you were ever employed or enrolled in a school under a name other than that used on this application:
*
Yes
No
Other
If you are employed now, may we contact your current employer?
*
Yes
No
Are you able to perform the essential duties of the position for which you are applying, either with or without accommodations?
*
Yes
No
Are you a veteran of the United States military service? If yes, please state branch of service:
*
Yes
No
Other
Please list any job-related professional, trade, business or civic activities, organizations and associations. (You may omit those which indicate race, religion, national origin, ancestry, sex, age, the existence of a disability or any other characteristic protected by law.)
Please provide the name, address, and telephone number of Reference #1 who is not related to you:
*
Please provide the name, address, and telephone number of Reference #2 who is not related to you.
*
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Please sign this statement.
*
Date
*
-
Month
-
Day
Year
Date
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Please sign this statement.
*
Date
*
-
Month
-
Day
Year
Date
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Authorization for Background Checks
After carefully reading this Background Check Disclosure and Authorization form, I authorize PALS LLC (“PALS”) to order my background report, including investigative consumer reports. I understand that PALS may rely on this authorization to older additional background reports, including investigative consumer reports, during my work as an independent contractor without asking me for my authorization again as allowed by law. I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities motor vehicle records agencies; if applicable, workers compensation injuries; all other private and public sector responsibilities of information; and any other person, organization, or agency with any information about or concerning me. Workers’ compensation information will only be requested in compliance with federal Americans with Disabilities Act and/or any other applicable federal, state or local law and only after a conditional offer is made. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing. I agree that PALS may rely on this authorization to order background reports, including investigative consumer reports, from companies other than ADP Screening and Selection Services without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid lie the signed original. I certify that all of the personal information I provided is true and correct.
Name
*
First Name
Last Name
Middle Name
*
Maiden Name or Other Name(s)
*
Years Used
*
Please check this box if you would like a free copy of your background check.
Yes
Signature
*
Date
*
-
Month
-
Day
Year
Date
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Background Check Information
Full Legal Name
*
First Name
Last Name
Middle Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Driver's License Number
*
State Issuing License
*
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Submit
Should be Empty: