Fill and Sign the Application for Employment Ward Medical Services Form

Application for EmploymentPage 1 of 8 APPLICATION FOR EMPLOYMENT (PRE-EMPLOYMENT QUESTIONNAIRE / AN EQUAL OPPORTUNITY EMPLOYER) PERSONAL INFORMATION DATE NAME , , LAST FIRST MIDDLE PRESENT ADDRESS , , STREET CITY STATE ZIP HOME PHONE # CELL PHONE # EMAIL ADDRESS DATE OF BIRTH IF HIRED, CAN YOU PROVIDE PROOF THAT YOU ARE LEGALLY ENTITLED TO WORK IN THE UNITED STATES? YES NO IF NOT, WHAT STEPS MUST BE TAKEN FOR YOU TO BEGIN EMPLOYMENT LAWFULLY? EMPLOYMENT DESIRED POSITION DATE YOU CAN START DESIRED SALARY ARE YOU CURRENTLY EMPLOYED? YES NO IF SO, MAY WE CONTACT THEM? YES NO HAVE YOU EVER APPLIED TO THIS CHURCH BEFORE? YES NO WHEN? (YEAR) Application for EmploymentPage 2 of 8 CURRENT CHURCH ARE YOU A MEMBER? EDUCATION EDUCATION NAME | LOCATION OF SCHOOL # OF YEARS ATTENDED DID YOU GRADUATE? HIGH SCHOOL COLLEGE POST-COLLEGE IN A PARAGRAPH DESCRIBE YOUR HIGH SCHOOL EXPERIENCE FORMER EMPLOYERS (LIST BELOW THE LAST FOUR EMPLOYERS, STARTING WITH THE LAST ONE FIRST) TO – FROM NAME OF EMPLOYER SALARY POSITION ______ - ______ : , $ , REASON FOR LEAVING TO – FROM NAME OF EMPLOYER SALARY POSITION ______ - ______ : , $ , REASON FOR LEAVING Application for EmploymentPage 3 of 8 TO – FROM NAME OF EMPLOYER SALARY POSITION ______ - ______ : , $ , REASON FOR LEAVING TO – FROM NAME OF EMPLOYER SALARY POSITION ______ - ______ : , $ , REASON FOR LEAVING WHICH OF THESE JOBS DID YOU LIKE THE BEST? WHAT DID YOU LIKE MOST ABOUT THIS JOB? REFERENCES (PLEASE GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR) NAME PHONE NUMBER ADDRESS BUSINESS YEARS KNOWN 1. 2. 3. IN CASE OF EMERGENCY Application for EmploymentPage 4 of 8 _____ _______ NAME ADDRESSPHONE ALL INFORMATION IN THIS APPLICATION IS HELD STRICTLY CONFIDENTIAL BY THE Church STAFF. ANSWERING YES TO ANY OF THE QUESTIONS MAY NOT NECESSARILY PRECLUDE YOUR INVOLVEMENT IN MINISTRY HERE AT CRPC. DO YOU USE ILLEGAL DRUGS? YES NO HAVE YOU EVER BEEN HOSPITALIZED OR TREATED FOR ALCOHOL OR SUBSTANCE ABUSE? YES NO HAVE YOU EVER BEEN ARRESTED FOR A CRIMINAL OFFENSE EXCLUDING MINOR TRAFFIC VIOLATIONS? YES NO HAVE YOU EVER BEEN ACCUSED, ARRESTED, OR CONVICTED FOR ANY SEXUALLY RELATED CRIME? YES NO HAVE YOU EVER BEEN ACCUSED, ARRESTED, OR CONVICTED FOR ANY ABUSE RELATED CRIME? YES NO IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE EXPLAIN: BEARING THESE THINGS IN MIND, WOULD YOU BE WILLING TO SUBMIT TO A BACKGROUND CHECK? YES NO “I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION AER TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FROM ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE.” Application for EmploymentPage 5 of 8 SIGNATURE___________________________________________ DATE (Type/Print Name) PLEASE ATTACH THE FOLLOWING:  RECENT PHOTO OF YOURSELF  A BRIEF TESTIMONY OF HOW YOU CAME TO KNOW JESUS CHRIST AS YOUR LORD AND SAVIOR I understand that Main Street Presbyterian Church is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, handicap or disability or any other category protected by Federal, State, or local law. As a religious organization, the Civil Rights Act of 1964 exempts Main Street Presbyterian Church against religious discrimination in employment on the basis of religion. All applicants and employees are required to adhere to Main Street Presbyterian Church’s Statement of Faith to be eligible for hire and in the course of their duties and responsibilities as an employee of Main Street Presbyterian Church. I authorize former and present employers, and professional, work, and personal references listed in the application and any other individuals I may name, to give Main Street Presbyterian Church or its designees any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release such parties from all liability for any damages that may result from furnishing such information to Main Street Presbyterian Church. I also authorize Main Street Presbyterian Church to provide truthful information concerning my employment with it to future employers, and I agree to hold it harmless for providing such information. I understand that Main Street Presbyterian Church reserves the right, to the extent permitted by law, to require drug and alcohol screening tests of an applicant or an employee either prior to employment or anytime during employment, and I hereby give my consent to any such tests. I consent to the release of the results of any such tests to Main Street Presbyterian Church or its designees. I release Main Street Presbyterian Church and its designees from any and all liability and damages which may result or arise from any drug and alcohol screening tests or the provision of information in connection with such tests. I understand that this employment application and any other documents are not promises of employment. Should I be employed, I understand that my employment will be on an “at-will” basis. I further understand that if I am employed, I may terminate my employment at any time, Application for EmploymentPage 6 of 8 with or without advance notice and that Main Street Presbyterian Church has a similar right. I understand that no manager, representative, or agent of Main Street Presbyterian Church 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. I agree to be bound by any additional employment standards as set forth in this application, the employee handbook, or agreed to between myself and Main Street Presbyterian Church at the time of hire. The information given by me on this application and during the interview process is true and complete in all respects, and all information requested in the application and hiring process will be provided on a timely basis. I agree that if the information is found to be false, misleading, or unsatisfactory in any respect (in Main Street Presbyterian Church’s judgment), I will be disqualified fro I acknowledge that Main Street Presbyterian Church may obtain a criminal history background screening on me for use in connection with my application and, if I am hired, my employment with Main Street Presbyterian Church. I also authorize Main Street Presbyterian Church to obtain this information periodically while I am employed. This application will be considered “active” for a maximum of one year. If you wish to be considered for employment after that time, you must reapply. Do not sign until you have read and understood these statements. SIGNATURE___________________________________________ DATE (Type/Print Name) BACKGROUND SCREENING CONSENT Applicant should complete all relevant information and sign and date the form. I, , hereby authorize Main Street Presbyterian Church and/or its agents to make an independent investigation of my background that may include: references, character, past employment, education, credit history (if applicable for position), audit criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for service now and, if applicable, during the tenure of my employment or service with Main Street Presbyterian Church. I release Main Street Presbyterian Church and its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all of the above referenced sources used. The following is my true and complete legal name and all the information is true and correct to the best of my knowledge: Application for EmploymentPage 7 of 8 Full Name (printed) Maiden Name or Other Names Used Social Security Number Date of Birth*: / / Present Address City State Zip How Long at Present Address? Former Address City State Zip How Long at Former Address? Please List All States and Counties of Residence Since Turning 18: STATE COUNTY 1. 2. 3. 4. Please circle any of the following states in which you have lived: CA, CO, DE, LA, MA, SD, VT, WV, WY Driver’s License Number State of License Signature of Appilcant: ___________________________________________ Date Application for EmploymentPage 8 of 8 (Type/Print Name) *NOTE: The above information is required for identification purposes only, and is in no manner used as qualifications for employment, internship, or services as a volunteer. Main Street Presbyterian Church abides by all applicable state and federal employment laws.