Employment Application

Position Applying For (check all that apply)

Residential Instructor (Direct Care Staff)

Residential Program Manager (RPM)

Night Residential Instructor (NRI)

Designated Coordinator (DC)

Health Coordinator (HC)

Other

I understand all of the requirements that are necessary to perform this job/position in a safe and satisfactory manner. I further understand that my employment with ELM Homes will be terminated if ELM Homes determines that I have not preformed my job in a safe and satisfactory manner.

I agree & understand

Yes

High School Name & Location

High School Years Completed

Undergraduate College/University Name

Undergraduate College/University Location

Undergraduate College/University Years Completed

Graduate/Professional Name

Graduate/Professional Location

Graduate/Professional Years Completed

Describe Course of Study

Describe any specialized training, apprenticeship, skills, and extra-curricular activities that you received, developed or were involved with while attending any of the above schools.

Describe any honors or awards you received during your education.

Describe any work you have performed with or for persons with disabilities/child care, whether paid or volunteer.

List any licenses or certifications you currently hold that are applicable to working with the disabled/child care.

Are you 18 years of age, or older?

Yes

If so can you provide proof of eligibility to work?

Yes

I do have a VALID Drivers License and I do understand that meeting all driver qualification is a requirement of the job

Yes

Have you ever filed an application with us before?

Yes

Have you ever been employed with us before?

Yes

Have you ever been known by any other name(s) which this facility will require to verify

Yes

If yes, give name(s)

On what date would you be available to work?

Are you available to work?

Full-Time

Part-Time

Subbing

Can you travel if the job requires it?

Yes

Employer 1 - Dates Employed - Please Include To / From Date Range

Employer 1 Reason For Leaving

Employer 1 Work Performed

Employer 2 - Dates Employed - Please Include To / From Date Range

Employer 2 Reason For Leaving

Employer 2 Work Performed

Employer 3 - Dates Employed - Please Include To / From Date Range

Employer 3 Reason For Leaving

Employer 3 Work Performed

Employer 4 - Dates Employed - Please Include To / From Date Range

Employer 4 Reason For Leaving

Employer 4 Work Performed

Employer 5 - Dates Employed - Please Include To / From Date Range

Employer 5 Reason For Leaving

Employer 5 Work Performed

Reference 1 Relationship

Reference 2 Relationship

Reference 3 Relationship

EMPLOYEE REFERENCE REQUEST FOR INFORMATION

TO WHOM IT MAY CONCERN: I hereby authorize ELM Homes to perform an investigation as may be necessary into my personal background/employment history. I further authorize the companies, agencies, or persons named below to give any information regarding my employment, character and qualifications, together with any information they may have regarding me whether or not it is in their records. I hereby release said companies, agencies, or persons from all liability for any damage for issuing this information. A photocopy or facsimile of this authorization shall be as valid as the original.

Reference Request

I Agree & Understand

Have you acquired any job-related special skills while in service with the United States military?

Yes

If yes, please describe:

Have you been convicted of a felony? Convictions will not necessarily disqualify an applicant from employment.

Yes

If yes, please explain:

Are you prevented from lawfully becoming employed in the country because of Visa or Immigration status?

Yes

Proof of citizenship or immigration status will be required upon employment in accordance with the Employment in Eligibility Verification (Form I-9).

Please provide a written statement as to why you wish to become employed with our organization. What contribution do you feel you can and will make for the betterment of our organization?

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION

Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et. Seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit ELM Homes to obtain a consumer report and/or an investigative consumer report which may include the following: 1. My employment records; 2. Records concerning any driving, criminal history, civil record, workersʼ compensation (post-offer only) and drug testing; 3. (For truck drivers only) In accordance with the Department of Transportation Motor Carrier Safety regulations, Section 382.413, information concerning alcohol and controlled substances for the past 2 years; 4. Verification of my academic and/or professional credentials, and information and/or copies of documents from any military service records. I understand that an “investigative consumer report” may include information as to my character, general reputation, personal characteristics, and mode of living, which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information.

I agree that a copy of this authorization as the same effect as an original. I herby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as ELM Homes from liability that might otherwise result from the request for use of an/or disclosure of any or all of the foregoing information. I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer-reporting agency that compiled the report, after I have provided proper identification.

I hereby authorize ELM Homes to obtain and prepare an investigative consumer report as set forth above, as part of its investigation of my employment application.

I hereby declare the information provided by me in the application for employment is true, correct and complete to the best of my knowledge (as is all the supplemental information submitted in conjunction with this application). I understand that if employed, any mis-statement or omission of fact on this application and supplemental information may result in my not being hired, or if employed, my termination. I authorize investigation of all statements contained in this application (and accompanying resume, if any).

I authorize you to obtain an investigative consumer report containing information obtained through personal interviews with my neighbors, friends, and acquaintances. This report, if obtained, may include information as to my character, general reputation, and personal characteristics. I further authorize investigation by law enforcement, and any and all state and federal agencies, employers or any other appropriate firms or agencies in any state. I understand that I have the right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of any such investigative report that is made.

In consideration of my employment, I agree to conform to the rules and regulations of ELM Homes and my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Company or myself. I understand that this application was completed by me, and that all entries in it and information in it are true, correct and complete to the best of my knowledge.

I further understand that this application is not, and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. I understand and agree that my employment is at-will and can be terminated by either party with or with out notice, at any time, for any reason or no reason. No one other than an officer of ELM Homes has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and then only in writing signed by the officer.

DISCLOSURE AND AUTHORIZATION FOR RELEASE OF BACKGROUND INFORMATION

As part of our hiring background and investigation, we may obtain consumer reports to prepare an investigative consumer report. The investigative consumer reports may consist of contacting all listed prior employers to verify your employment history. It may also include, but not be limited to criminal history reports and driving history records. Under the provisions of the Fair Credit Reporting Act (15 USC at 1681-1681u) as amended, before we can seek such reports, we must have your written permission to obtain the information. You have the right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation. You are also entitled to a copy of your Consumer Rights Under the Fair Credit Reporting Act.

Authorization and Release to Obtain Information

I Agree & Understand

Please Read Carefully

As an affirmative action employer, we must monitor our equal employment opportunity and affirmative action program, and report the results to government agencies. Please help us gather this information by identifying your sex, race or ethnicity, and disability status on this form.

Providing this information is completely voluntary. If you choose not to provide some or all of this information, you will not be subject to any negative or adverse treatment.

I have chosen NOT to complete this section

I understand and will complete section

The information you provide will be used only to monitor our compliance with equal opportunity laws and regulations, and for no other purpose. * When we receive this section, we will immediately place it in a confidential file separate from your application.

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa.

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Disability- Are you a person with a disability?

Yes

Sex- Select one

Female

Male

* This section is not used for employment decisions. If you have a disability and need an accommodation so you can perform the duties of the job for which you are applying, please notify us in some other manner.

Please sign your application by entering your full name

PDF Employment Application

Employment Application