CGS APPLICATION FOR EMPLOYMENT

Application for Employment

Applicants May be Tested for Illegal Drugs
Date

MonthDayYear
Date
First Name*
Last Name*
Middle Name
Any other Last Name or Surnames
Street Address*
City*
State*
Zip Code*
Telephone*
Are you over 18 years of age*
Position Applied for*
Salary Desired*
Are you legally eligible for employment in the United States?*
Employment Desired*
When available for work?*
How did you hear about CGS?*
Do you have any relatives currently employed by CGS Family Partnership or a member of its Board of Directors?*
If so, who and what is the relationship
Education
High School: Name of School
High School: Location/ Complete mailing address
High School: # of Years Completed
High School: Major & Degree
College: Name of School
College: Location/ Complete mailing address
College: # of Years Completed
College: Major & Degree
Bus. or Trade School: Name
Bus. or Trade School: Location/ Complete mailing address
Bus. or Trade School: # of Years Completed
Bus. or Trade School: Major & Degree
Professional School: Name
Professional School: Location/ Complete mailing address
Professional School: # of Years Completed
Professional School: Major & Degree
Professional Licenses or Memberships
Other Trainings/ Degrees/ Internships/ Volunteer Positions
Do you have a valid drivers license?*
Do you have a reliable means of non public transportation that will enable you to perform the duties to your job?*
Have you had any accidents during the past 3 years?*
How many?
Have you had any moving violations during the past 3 years?*
How many?
Please list 2 Professional References other than relatives or previous employers
Name of Reference 1*
Position*
Company*
Address*
Telephone*
Name of Reference 2*
Position*
Company*
Address*
Telephone*
Please list your work experience beginning with your most recent job held.
Name of Employer 1*
Address*
City, State, Zip Code*
Phone Number*
Name of Last Supervisor*
Employment Start Date*
Employment End Date*
Your last job title*
Reason for leaving (Be specific)*
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company*
Do you have another employer to add?
Name of Employer 2
Address
City, State, Zip Code
Phone Number
Name of Last Supervisor
Employment Start Date
Employment End Date
Your last job title
Reason for leaving (Be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company
Do you have an additional employer to add?
Name of Employer 3
Address
City, State, Zip Code
Phone Number
Name of Last Supervisor
Employment Start Date
Employment End Date
Your last job title
Reason for leaving (Be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company
Do you have another employer?
Name of Employer 4
Address
City, State, Zip Code
Phone Number
Name of Last Supervisor
Employment Start Date
Employment End Date
Your last job title
Reason for leaving (Be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company
May we contact your present employer?*
Have you ever been discharged or asked to resign from a job?*
If yes, why?
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.*
CODE OF CONDUCT ACKNOWLEDGEMENT

CGS FAMILY PARTNERSHIP, INC.

1.       I understand CGS Family Partnership, Inc. (CGS) maintains a Code of Conduct as part of its Corporate Compliance Plan. This Code establishes general standards of conduct, policies, and practices to conduct CGS business lawfully and ethically. I understand standards include, but are not limited to, matters of waste, fraud, and abuse; preserving privacy and security; ethical service, documentation and billing practices; conflicts of interests; employment standards; and workplace conduct.

2.       I understand all CGS employees are required to comply with such standards, including adherence to a Code of Conduct, Corporate Compliance Plan, applicable laws and regulations, health care reimbursement program requirements, as well as CGS policies and expectations on ethical conduct and business practices.

3.       I know standards of conduct are outlined in CGS Family Partnership’s Corporate Compliance Handbook, Employee Handbook (aka Employee Manual), as well as other written policies and procedures. I understand I will receive access to CGS written standards, policies, and procedures directly or through access to CGS’ intranet and will maintain access throughout my service at CGS.

4.       I acknowledge that I am responsible for reviewing and adhering to these standards, including the Corporate Compliance Plan, including Section 6032 of the federal Deficit Reduction Act of 2005.

5.       I understand corrective action policies and practices are established regarding individuals who violate laws, regulations, standards, and operating policies. I understand that acts or allegations of serious offenses or crimes may preclude me from employment with CGS.

6.       I understand CGS maintains a Compliance Officer, who oversees compliance activities of the organization and may report to the CEO or Board of Directors on compliance matters.

7.       I know employees and leaders have an obligation to report actual or suspected misconduct or violations of the Code of Conduct or Compliance Plan, as well as actual or suspected violations of laws, regulations, and standards. I recognize I can forward concerns to my Supervisor, the Compliance Officer, or Designee, along with any evidence or proof of misconduct. I understand whenever appropriate, the Compliance Officer, or Designee, will be notified and may lead an investigation or response to the matter. I will make all reports in good faith, based on reasonable and credible information. I understand that I have the right to ask to remain anonymous, but also, I may need to reveal my identity, if necessary, to fully investigate or respond to the issue and, in such an event, I may no longer maintain anonymity.

8.       I understand CGS’ policy that no retaliatory or disciplinary action will be taken against any employee who makes a good faith complaint of what is reasonably and truly believed to be an act of wrongdoing, violation of law, this Code of Conduct, or the Compliance Plan; nor for their assistance in the investigation of a good faith complaint. Good faith employee complaints of violations of law or policy will be investigated in a fair and objective manner. I also understand a staff member may be subject to corrective action if reasonably determined the report of wrongdoing was knowingly fabricated, distorted, exaggerated or minimized to injure someone or to protect themselves or others. Further, a Staff Member whose report of possible misconduct contains admissions of personal wrongdoing will not be guaranteed protection from corrective action.

9.       I understand if I am named to any list of individuals excluded or debarred from participation in federal or state reimbursement programs, my employment or engagement with CGS may be terminated.

10.   I understand that compliance with the Code of Conduct is a condition of employment or engagement with the organization, but this is not an acknowledgment of any expressed or implied rights to continued employment or engagement with CGS.
I affirm I have read and understand the above and will comply with the Code of Conduct. I understand any questions concerning the Code of Conduct will be directed to the Compliance Officer, or Designee, unless said Officer is the subject of the matter, in which case, I may address questions/concerns to the Chief Executive Officer or Human Resources Director.
Signature*

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I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for CGS Family Partnership to hire me. If I am hired, I understand that either CGS Family Partnership or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of CGS Family Partnership has the authority to make any assurance to the contrary. I attest with my signature below that I have given to CGS Family Partnership true and complete information on this application. No requested information has been concealed. I authorize CGS Family Partnership to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
Signature*

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Date
Application Form Waiver

Please Read Carefully
In exchange for the consideration of my job application by CGS Family Partnership (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of CGS Family Partnership Inc., or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by CGS Family Partnership. Both the undersigned and CGS may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.
I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, driving record, criminal record and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
Signature

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Equal Opportunity Employer

CGS Family Partnership, Inc. values diversity and is proud to be an Equal Employment Opportunity Employer. CGS Family Partnership, Inc. prohibits discrimination. Employment decisions, including hiring, promoting, discipline, or discharge will be based on job requirements, individual qualifications, merit, performance, and business need without regard to non-merit factors such as race, color, creed, religion, sex, gender identity, gender expression, national origin, political affiliation, sexual orientation, marital status, pregnancy, non-disqualifying physical or mental disability, genetic information, age, membership in an employee organization, retaliation, parental status, military or veteran status, or any other status protected under law.
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Application for Employment

Education

Please list 2 Professional References other than relatives or previous employers

Please list your work experience beginning with your most recent job held.

Please read carefully before signing

Application Form Waiver