CSS Employment Application

Community Support Services, Inc. Employment Application

Complete this employment application based on the provided PDF. Recreate the form structure as closely as possible and fill out all required sections.
General Information
Position Applied For
Date of Application

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Are you legally eligible to work in the United States?
Desired Hourly Wage
Are any of your relatives presently employees, Board Members, or Service Recipients with our agency?
If Yes, name and relationship
Have you ever worked for our agency before?
If Yes, list position, title and dates of employment
How did you hear about this employment opportunity?
If job fair, list location, if other, explain
If employee referral, please provide first and last name of employee
DSP / Job-Specific Information

IF YOU ARE APPLYING FOR A DSP POSITION, PLEASE ANSWER THE FOLLOWING QUESTIONS:

Rows	Yes	No
Are you willing to help individuals who are unable to toilet themselves.
Are you willing to help individuals who are unable to feed themselves.
Are you willing to help individuals where there is a possibility that an individual may hit, kick, or bite you.
Are you willing to help individuals that may exhibit inappropriate sexual behavior or uses profanity.
Are you willing to help lift and/or assist individuals that are non-ambulatory.
Are you willing to learn to use mechanical devices to assist individuals.

Are you at least 18 years of age?
Do you have a valid driver’s license and reliable transportation?
Are you able to provide proof of insurance coverage?
Which of the following types of support have you provided?

Other
Are you certified in CPR and First Aid?
Do you have experience working with individuals with developmental disabilities?
Which of the following types of support have you provided?
Please describe any other job-specific qualifications, skills, or relevant experience.
Education and Employment History
School Name
City / State
Highest Level Completed
Field of Study / Major
Dates Attended

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Education Completed

Other
Have you ever been discharged from any employment or asked to resign?
If Yes, Explain
Employment History - Previous Employer 1
Employer Name 1
Job Title 1
Employment Dates 1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Responsibilities 1
Reason for Leaving 1
Employment History - Previous Employer 2
Employer Name 2
Job Title 2
Employment Dates 2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Responsibilities 2
Reason for Leaving 2
Additional Qualifications and Work History Questions
Additional qualifications you would like us to consider

Other
Do you have any certifications or licenses relevant to this position?
If yes, please list your certifications or licenses
How would you describe your attendance and punctuality?
Please describe any attendance issues or work schedule limitations
Please share any additional information that supports your application
References
Business Reference 1 - Name

First NameMiddle NameLast Name
Business Reference 1 - Company/Relationship
Business Reference 1 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Reference 1 - Email Address
example@example.com
Business Reference 1 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business Reference 2 - Name

First NameMiddle NameLast Name
Business Reference 2 - Company/Relationship
Business Reference 2 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Reference 2 - Email Address
example@example.com
Business Reference 2 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business Reference 3 - Name

First NameMiddle NameLast Name
Business Reference 3 - Company/Relationship
Business Reference 3 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Reference 3 - Email Address
example@example.com
Business Reference 3 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Personal Reference 1 - Name

First NameMiddle NameLast Name
Personal Reference 1 - Relationship
Personal Reference 1 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Reference 1 - Email Address
example@example.com
Personal Reference 1 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Applicant Certification, Signature, and Disclosure
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE; I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to the Human Resource Department before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

CSS provides equal employment opportunities (EEO) to all employees and applicants for employment without regard race, color, religion, sex, gender identity, sexual orientation, pregnancy, status as a parent, national origin, age, disability (physical or mental), family medical history or genetic information, political affiliation, military service, or other non-merit based factors. These protections extend to all terms and conditions of employment, including recruitment and hiring practices, appraisal systems, promotions, training, and career development programs.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by all of the Agency rules and regulations, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the Agency or me, I further understand that no representation, whether oral or written by any representative or agent of the Agency, at any time, can constitute a contract of employment. I understand that the Agency and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment other than in a document signed by the President/CEO, or to make any agreement contrary to the foregoing. If hired, you will need to provide documents relating to your identity and employment eligibility and driving record. All offers of employment are contingent upon your ability to pass all required checks, including reference checks, background checks including: State Police fingerprint check, HCWR, OIG, DCFS, IL Sex Offender, TB test, any other required tests, and presentation of all required documentation.
Are you able to perform the duties of the job with or without reasonable accommodations?
This is to notify you that a background and reference check will be conducted on you for employment purposes.

By signing the release below, I hereby authorize Community Support Service, Inc. to contact any and all corporations, former employers, educational institutions, law enforcement agencies, city, state, county, and federal courts, military services to release information about my background including but not limited to, information about employment, education, training, driving record, criminal record and general public records history to Community Support Services, Inc.

I release from all liability all persons, companies, schools supplying such information. I indemnify Community Support Services, Inc. against any liability, which may result from making such requests. This release shall remain in effect for the length of my employment. I understand and I may have a right to request additional disclosures regarding the nature and scope of the investigation.

I believe to the best of my knowledge that all information I have provided is accurate, true and correct and that I fully understand the terms of this release.
I agree to the above background and reference check
Name

First NameLast Name
Applicant Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Community Support Services, Inc. Employment Application

General Information

DSP / Job-Specific Information

Education and Employment History

Additional Qualifications and Work History Questions

References

Applicant Certification, Signature, and Disclosure