Employment Application - Champlain Community Services

Today's Date mm/dd/yyyy

APPLICANT INFORMATION

First Name

Middle Initial

Last Name

Street Address

City

State

Zip

Phone

Position applying for

Are you a citizen of the United States?YesNo

If no, are you authorized to work in the U.S.?YesNo

Have you ever worked for CCS?YesNo

If yes, when and which position?

How did you hear about CCS?

CCS WebsiteJob FairJob PostingDept. of LaborEmployeePublicationCollegeNewspaperOther

If Publication, College, Newspaper, or Other, which one?

EDUCATION

HIGH SCHOOL

Diploma or equivalent? YesNo

COLLEGE

Did you graduate? YesNo

Degree

OTHER

Did you graduate? YesNo

Degree

REFERENCES

Please list three professional references:

REFERENCE 1

Full Name

Relationship

Phone

Company

REFERENCE 2

Full Name

Relationship

Phone

Company

REFERENCE 3

Full Name

Relationship

Phone

Company

PREVIOUS EMPLOYMENT

Start with your present or last job and include all of your past employment, any job related military service, volunteer activities or part time employment. Make sure phone numbers are accurate and complete. If you need additional space, please type in the text box below the last employment entry.

PREVIOUS EMPLOYER 1

Company

Address

Phone

Supervisor

Your Job Title

Responsibilities

From:

To:

Reason for leaving:

May we contact your previous supervisor for a reference? YesNo

PREVIOUS EMPLOYER 2

Company

Address

Phone

Supervisor

Your Job Title

Responsibilities

From:

To:

Reason for leaving:

May we contact your previous supervisor for a reference? YesNo

PREVIOUS EMPLOYER 3

Company

Address

Phone

Supervisor

Your Job Title

Responsibilities

From:

To:

Reason for leaving:

May we contact your previous supervisor for a reference? YesNo

Please list company names and positions held if more than three previous employers

Have you ever been formally disciplined, asked to resign or been terminated by a former employer for any reason? If yes, please explain:

CONVICTION INFORMATION

Record of convictions(s) on criminal charges or substantial findings, will not necessarily bar an applicant from consideration for employment. This data will be one factor considered in light of the relationship of the nature of the conviction to the position for which you are applying.

Have you ever been convicted or had findings substantiated against you for acts related to emotional, physical or sexual abuse? YesNo

If yes, please explain:

Have you ever been convicted of an offense related to sexual misconduct or violence? YesNo

If yes, please explain:

Have you ever been convicted of a motor vehicle violation in the past 10 years? YesNo

If yes, please list all violations:

PRE-EMPLOYMENT AUTHORIZATION & RELEASE

I understand that Champlain Community Services will verify all data that I have provided on my application, resumé, related documents and interviews. I authorize and consent to have Champlain Community Services carry out inquiries connected with my application for employment, contract-for-services or volunteer work. I further understand these inquiries may include (but are not limited to) requests for information about my character, work habits, performance, experience and qualifications, reasons for terminations from previous employment and other information deemed relevant to my application.

I acknowledge and agree that references, prior employers and other individuals or businesses providing Champlain Community Services with information about me are doing so at my request and for my benefit.

I hereby hold harmless Champlain Community Services and the individuals or businesses providing information related to my application for employment/contract or volunteer position. I hereby release these entities and persons from any and all liability for damages of any nature as a result of obtaining or furnishing such reference and background information.

I acknowledge and understand that Champlain Community Services follows an “employment-at-will” policy and practice. As a result, if I am hired, Champlain Community Services, as the employer, or I, as the employee, may terminate my employment at any time and for any reason that is consistent with Champlain Community Services policies and applicable state and federal laws, or my employment may be terminated for no reason.

I hereby certify that all statements made by me on this application, my resumé, documents related to my application for employment/contract or volunteer position are accurate and true to the best of my knowledge. I understand and agree that any falsification or omission in this application and background information may result in refusal to employ me, contract with me or place me in a volunteer position. Also, based on any provision (or causing the provision) of false information or omission of information, Champlain Community Services may terminate my employment, contract or volunteer work. If I become employed, enter into a contract or am placed in a volunteer position with Champlain Community Services, then I agree to abide by all the Agency’s policies, procedures, rules and regulations, any applicable code of ethics, professional licensure rules and applicable laws.

I acknowledge and agree that, if I choose to submit this Employment Application to Champlain Community Services via fax or electronically (for example, by submitting a pdf file using CCS’ website), then – by doing so – my pre-employment authorizations, certifications, releases, and agreements outlined above are valid, effective, and binding with a copy of my signature or without any signature and are granted by virtue of my submission of this application by fax or electronic means, respectively.

I understand and agree to the above statements.