Employment Application Form


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NameEmployment Application Form
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Successful Transitions LLC

Employment Application Form

PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE







APPLICATION FOR EMPLOYMENT

APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS




PLEASE COMPLETE PAGES 1-5.

DATE

Name

Last First Middle Maiden

Present address

Number Street City State Zip

How long

Social Security No. _______ – _____ – _________

Telephone ( )

If under 18, please list age


Position applied for (1)


and salary desired (2)

(Be specific)

Days/hours available to work

No Pref Thur

Mon Fri

Tue Sat

Wed Sun

How many hours can you work weekly? Can you work nights?

Employment desired FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME

When available for work?






TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION
(Complete mailing address)


NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

High School




























College




























Bus. or Trade School




























Professional School































HAVE YOU EVER BEEN CONVICTED OF A CRIME? No Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.



PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE







APPLICATION FOR EMPLOYMENT




DO YOU HAVE A DRIVER’S LICENSE? Yes No

What is your means of transportation to work?

Driver’s license
number State of issue _______ Operator Commercial (CDL) Chauffeur


Expiration date

Have you had any accidents during the past three years?

How many?

Have you had any moving violations during the past three years?

How Many?




OFFICE ONLY







Yes Yes Word Yes

Typing No _____ WPM 10-key No Processing No _____ WPM

Personal Yes PC

Computer No Mac

Other

Skills




Please list two references other than relatives or previous employers.

Name

Name

Position

Position

Company

Company

Address

Address





Telephone ( )

Telephone ( )




An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.


































PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE







APPLICATION FOR EMPLOYMENT




MILITARY







HAVE YOU EVER BEEN IN THE ARMED FORCES? Yes No

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? Yes No

Specialty Date Entered Discharge Date




Work Experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name.
Attach additional sheets if necessary.







Name of employer
Address


Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code
Phone number





From

To

Start

Final




Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
















Name of employer
Address


Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code
Phone number





From

To

Start

Final




Your Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.















PLEASE PRINT ALL INFORMATION REQUESTED EXCEPT SIGNATURE







APPLICATION FOR EMPLOYMENT

Work experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name.
Attach additional sheets if necessary.







Name of employer
Address


Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code
Phone number





From

To

Start

Final




Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
















Name of employer
Address


Name of last supervisor

Employment dates

Pay or salary

City, State, Zip Code
Phone number





From

To

Start

Final




Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.



















May we contact your present employer? Yes No

Did you complete this application yourself Yes No

If not, who did?



PLEASE READ CAREFULLY

APPLICATION FORM WAIVER


In exchange for the consideration of my job application by Successful Transitions LLC (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Successful Transitions LLC, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and Successful Transitions LLC may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts such as but not limited to criminal or civil crime, called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of sixty (90) days, and further that at any time during the probationary period or thereafter, my employment relation with Successful Transitions LLC is terminable at will for any reason by either party.

Signature of applicant__________________________________________ Date: ___________________


Successful Transitions LLC is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.


Thank you for completing this application form and for your interest in our business.


Successful Transitions LLC Interview and Reference Check Questionnaire

This must be completed before any employee is hired and scheduled for training…No Exceptions

  1. Tell me what you know about Therapeutic Residential Facilities and its purpose. (Clinical & Technical Knowledge). Scale 1 2 3

     

  1. This is a 24 hour facility meaning we work holidays, snow days, ice days, hot days, hurricane days, and every other day of the year. We do not shut down. What is your availability? (Technical Knowledge). Scale 1 2 3

     

  1. How well do you cook/prepare meals? What is your specialty? (Clinical & Technical Knowledge). Scale 1 2 3

     

  1. What does the word therapeutic mean to you? (Please do not tell them what this is only write down their response). (Clinical Knowledge). Scale 1 2 3

     

  1. What are some examples of the diagnosis you may see in a Residential Level III facility? (Clinical Knowledge). Scale 1 2 3

     

  1. Give me an example of multitasking? How do you prioritize your tasks? (Clinical Knowledge). Scale 1 2 3

     

  1. What is an example of a difficult decision you have made and how did you make the decision? (Analytical Skill). Scale 1 2 3

     

  1. What does cultural diversity mean to you? How can you incorporate cultural awareness in a residential treatment facility (Cultural Awareness)? Scale 1 2 3

     

  1. What are your computer skills (include if you can email, attach documents, save documents in appropriate files, how to select a printer, and open documents…be prepared to demonstrate your skills). Technical Knowledge). Scale 1 2 3

     

  1. You are at the skating rink with a co-worker and clients. A client remembers he left his flip flops in the car. The client asks if he could go to the car and get his shoes. Your co-worker is engaged with two of the consumers while you are engaged with the consumer and his peer. In addition, the car is within eye distance. Although the policy states to not allow consumers to handle the keys, the consumer has exhibited leadership skills in the past and the car is within eye distance. How do you handle this situation? (Decision Making). Scale 1 2 3

     

  1. How would you approach the following challenge…? A consumer is very defiant and refuses to follow the procedures. You try to coach, persuade, and convince the consumer to comply. Instead the consumer stands in your face, calls you a fat ass, ignores your authority, and threatens you. You begin to feel enraged about the current events. How do you handle this situation? (Decision Making & Clinical Skills). Scale 1 2 3

     

  1. A consumer gets angry with a peer and goes into her room. When staff check with the consumer you see that she is taking his/her nails and is scratching her arm consistently. What do you do? (Decision Making). Scale 1 2 3

     

  1. Its 1:30pm and your co-worker is scheduled to be off at 2pm. A consumer had an incident and the incident reports needs to be completed. Typically the lead staff generates the report; however, your co-worker does not have enough time to complete the report before his/her shift ends. Keep in mind the lead staff was the first to learn of the incident; therefore, he/she has most of the details. What do you do? (Interpersonal Skills). Scale 1 2 3

     

  1. What are your long term career plans (next five years)? Scale 1 2 3

     

  1. Is there anything else you would like me know about you? (Interpersonal Skills). Scale 1 2 3

     

Score: ________ (42 being the Highest and 28 being the minimum required)

Must have a 2 in at least each one of the competencies: Technical knowledge, Cultural awareness, Analytical skills, Decision-making, Interpersonal skills, Communication skills; and Clinical skills

References Check 1

(Please provide at least two references; one must be a former employer…no exceptions)

___________________________________, __________________________, _________________

Name of Reference Relation to Applicant Number

1. Do you think the candidate is qualified to assume these responsibilities? Why or why not?

2. How did the candidate perform with regard to________________?

3. Is this person a team player or does he/she excels by working alone?

4. What was the candidate's attendance record? Was the candidate on-time and dependable?

5. What are the candidate's strongest qualities?

6. Is the candidate eligible for rehire?

7. On a scale of 1-10, how would you rate this candidate’s work ethics?

Reference Check 2

(Please call at least two references; one must be a former employer…no exceptions)

___________________________________, __________________________

Name of Reference Relation to Applicant

1. Do you think the candidate is qualified to assume these responsibilities? Why or why not?

2. How did the candidate perform with regard to________________?

3. Is this person a team player or does he/she excels by working alone?

4. What was the candidate's attendance record? Was the candidate on-time and dependable?

5. What are the candidate's strongest qualities?

6. Is the candidate eligible for rehire?

7. On a scale of 1-10, how would you rate this candidate’s work ethics?



Revised 10/9/12

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