JOB APPLICATION General Applicant Information ALL FIELDS ARE REQUIRED. If a field is not applicable, mark as N/A. NO EXCEPTIONS. Do not leave any blank spaces. Incomplete application will not SUBMIT. Today's Date Job You are Applying For Social Security Number SC Driver's License Number Last Name First Name Initial Date of Birth Street Address City State Zip Mailing Address (If Different) Home Phone Work Phone Other Phone If you have lived in other states within the past ten years, please indicate previous address below: City State Zip Code May we contact you at work? YesNo Are you 18 years of age or older? YesNo Are you 21 years of age or older? YesNo Job for which you are applying List only one job per application. Do not leave blank spaces. Job Title Job Number If you are applying for a Substitute or Part-Time job, indicate days and hours you are available to work Why are you applying for this position? Have you ever field an application with us before? YesNo If yes, give date Have you ever been employed with us before? YesNo If yes, give date Are you related to anyone presently employed by us? YesNo If yes, please name and indicate how you are related? Are you related to member of our governing body? YesNo If yes, please name and indicate how you are related? Are you currently employed? YesNo Have you ever been convicted of a crime? YesNo If yes, what crime? Are there any violations or charges against your driving record?YesNo If yes, please explain Do you have any experience working with people disabilities?YesNo If yes, please explain Have you every worked with Department of Disabilities or another provider agency of DDSN services? YesNo If yes, please explain Please indicate below with a check if you are skilled in the use of any of the following: MS WindowsData EntryMS WordMS ExcelMS Access Other Specify Education Are you a high school graduate? YesNo If No, Have you earned a GED? YesNo Name and address of High School Name and address of College or University Course of study Degree Did you graduate? YesNo Years completed Name and address of Graduate school Course of study Degree Did you graduate? YesNo Years completed Other school (Please specify) Course of study Degree Employment Experience Start with most recent. Do not leave any blank spaces. Present or Most Recent place of Employment Phone # Mailing Address City State Zip Code Date Employed From Date Employed To Position you held Your Supervisor Starting salary/Hourly rate Ending salary/Hourly rate Reason for leaving Next most recent place of employmentiii Phone # Mailing Address City State Zip Code Date Employed From Date Employed To Position you held Your Supervisor Starting Salary/Hourly Rate Ending Salary/Hourly Rate Reason for Leaving Next most recent place of employment Phone # Mailing Address City State Zip Code Date Employed From Date Employed To Position you held Your Supervisor Starting Salary/Hourly Rate Ending Salary/Hourly Rate Reason for Leaving Professional References List three past or present employers or supervisors who have supervised you in your employment. Do not list personal references. If you have never been employed, then you may use teachers, ministers, or guidance counselors. Present/Past Employer or Supervisor Mailing Address City State Zip Code Phone Number Your Job Title Present/Past Employer or Supervisor Mailing Address City State Zip Code Phone Number Your Job Title Present/Past Employer or Supervisor Mailing Address City State Zip Code Phone Number Your Job Title Voluntary Information If contacted by a representative CCBDSN regarding scheduling an interview, please check here if special accommodations would be required. Do you receive Food Stamps or Family Independence benefits (This is used to comply with the Family Independence Act.)? YesNo Certification Please read and initial each paragraph below. If there is any part of this information that you do not understand, please ask before signing (CCBDSN). I hereby authorize CCBDSN to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and further, authorize my current and former employers to disclose to CCBDSN any and all letters, reports, and other information pertaining to my employment with them, without giving me prior notice of such disclosure. In addition, I hereby release CCBDSN, my current and former employers, all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. Iunderstand that if offered employment, the offer may be contingent upon my passing a pre-placement PPD, drug screen and physical examination. By signing this application, I voluntarily agree to submit to these medical screenings may result in withdrawl of the employment offer. I give my consent for all medical screenings result to be released to CCBDSN, or its representative, upon request. I hereby certify that I have not knowingly withheld any information that might adversely affect my opportunities for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or any documents used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I understand that nothing contained in the application or conveyed to me during any interview which may be granted is intended to create an employment contract, implied or explicit, between me and CCBDSN. I addition, I understand and agree that if I am employed, my employment relationship with CCBDSN is strictly voluntary and of an "at will" nature. I understand that if employed, my employment is for no definite period of time and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or CCBDSN, and that mo promises or representations contrary to the foregoing are binding on CCBDSN unless made in writing and signed by an authorized executive of this agency. I hereby certify that I have never been involved in or convicted of a substantial case of abuse or neglect and grant permission for CCBDSN to conduct a criminal background investigation to further verify this fact. I understand that if offered employment, I will, as a condition of employment, be required on my first day of employment to submit proof of my identity and legal right to work in the United States. I understand that if the position applied for requires driving in the course of work, I will be required to possess a current and valid South Carolina driver's license and understand that I will be required to provide a copy of my official driving record.