Serving people with Developmental Disabilities, recognizing their worth, affirming their ability to contribute, and striving to promote dignity in all relationships.
APPLICATION FOR EMPLOYMENT
NAME_______________________________________APPLICATION DATE_____________________
ADDRESS_________________________________________________________________________
________________________________________________________________________________
PHONE #_______________________Cell#_______________________Are you over 21?______
EMAIL ADDRESS___________________________________________________________________
POSITION APPLYING FOR:__________________________________________________________
LICENSED DRIVER? Yes______No_______ Driver's License#_________________State_____
Since the job will involve driving an agency vehicle, we need a more detailed driving history. A copy of your Motor Vehicle Record is required for employment. Please provide a copy of your record and give details requested below.
Have you ever had a DUI? ______________If so, give date________________________
Was license ever suspended?_____________If so, reason__________________________
Accidents (number and type)____________________________________________________
Tickets in last 3 years ( e.g., speeding, etc.)________________________________
SCHOOLING, COLLEGE, GRADUATE TRAINING: We will need to see verification of your education in the form of transcripts, diploma, license or other credential.
High School Graduate yes/no. GED,yes/no. School_____________City________State____
College(s) 1. Name of school and location______________________________________
Years attended______________________Degree Received?____________
2. Name of school and location______________________________________
Years attended______________________Degree Received?____________
HEALTH
Rules and regulations require that we check the physical and emotional health of prospective employees in order to properly protect the health and safety of those we serve.
What is the condition of your health? Excellent_______ Good_______ Fair_______ Poor_______
Do you have any illnesses, physical limitations or conditions which would interfere with your ability to perform this job or which might be aggravated by the position for which you are applying?_______If yes, please explain___________
EMPLOYMENT EXPERIENCE -- start with your present or most recent position. Unless the information is specifically listed on your resume, please fill in all blanks.
1. EMPLOYER____________________________________________JOB TITLE______________ ADDRESS______________________________________________PHONE______________________
______________________________________________________SUPERVISOR________________
EMPLOYED FROM___________________TO________________REASON FOR LEAVING___________
SALARY______________________MAY WE CONTACT THIS EMPLOYER?______________________
2. EMPLOYER____________________________________________JOB TITLE_______________ ADDRESS______________________________________________PHONE______________________
___________________________________________SUPERVISOR__________________________
EMPLOYED FROM___________________TO________________REASON FOR LEAVING____________
SALARY______________________MAY WE CONTACT THIS EMPLOYER?______________________
3. EMPLOYER____________________________________________JOB TITLE________________
ADDRESS______________________________________________PHONE________________________________________________________________SUPERVISOR____________________________
EMPLOYED FROM___________________TO________________REASON FOR LEAVING____________
SALARY______________________MAY WE CONTACT THIS EMPLOYER?______________________
4. EMPLOYER____________________________________________JOB TITLE_______________
ADDRESS______________________________________________PHONE______________________ __________________________________________SUPERVISOR____________________________
EMPLOYED FROM___________________TO________________REASON FOR LEAVING___________
SALARY______________________MAY WE CONTACT THIS EMPLOYER?______________________
Have you ever been fired from a previous job? Yes_____ No____ Have you ever had a professional license revoked?________If yes, give date and explain details.______________________________________________
TRAINING AND EXPERIENCE: Please summarize any particular training (not covered earlier in this application) or any practical experience you have had which would be useful in the position for which you are applying. Be as specific as possible regarding the nature of the training or experience and the length of your involvement in it.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
REFERENCES--Professional references are preferred. At least 2 must be familiar with your work performance.
Three references are necessary. Incomplete or inaccurate information will delay the hiring process.
NAME______________________________________________________Phone_________________
ADDRESS________________________________________LENGTH OF ACQUAINTANCE___________
_______________________________________WHAT CAPACITY______________________
NAME______________________________________________________Phone_________________
ADDRESS________________________________________LENGTH OF ACQUAINTANCE___________
_______________________________________WHAT CAPACITY______________________
NAME______________________________________________________Phone_________________
ADDRESS________________________________________LENGTH OF ACQUAINTANCE___________
________________________________________WHAT CAPACITY______________________
How did you hear about the job? (website, craigslist, paper, friend referred, school)
___________________________________________________________________________________
AGREEMENT (Please read each statement carefully before signing)
“Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in Section 18-8-503, C.R.S., and, upon conviction thereof, shall be punished accordingly.”
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at a decision for employment. In the event of employment, I understand that false or misleading information given in this application or during the interview may lead to my discharge. I understand that this application or subsequent employment does not create a contract of employment and does not guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice.
I have read, understand, and by my signature consent to these statements.
Signature_______________________________________________________________Date___________
ADDENDUM TO APPLICATION
*CRIMINAL RECORD CHECK AND CHECK OF THE CENTRAL REGISTRY OF CHILD PROTECTION
Under rules of the Colorado Department of Social Services, all employees of child care facilities must submit fingerprints to the Colorado Bureau of Investigation (CBI) and/or to the FBI for criminal record checks within 5 days of employment. Roundup must
request that the employee provide more detailed information regarding any criminal record. Roundup will terminate the employment of any person who has been convicted or entered into a deferred judgment agreement for the following types of crimes:
1) Any crime of incest, child abuse, child sexual abuse, kidnapping of a child, unlawful sexual behavior, crime committed against a vulnerable adult, or murder;
2) Any crime which involved child prostitution or the sale or possession of sexually explicit materials harmful
to children;
3) Any felony for which an individual has not yet completed the sentence;
4) Any felony of a violent nature including but not limited to assault, kidnapping, or robbery;
5) Any felony related to the sale of a controlled substance within the last ten years;
6) Any crime which adversely reflects upon the character and suitability of the employee, posing a threat to the health, welfare and safety of the children or adults we serve.
The cost of the criminal record check is incurred by the employee and will be deducted from the employee's first paycheck, unless otherwise arranged with the Executive Director. The employee will be reimbursed for this expense upon completion of six months of employment. See current cost of criminal record check at bottom of this addendum.
Roundup is also required to submit the names of new employees to the Central Registry of Child Protection to assure there are no confirmed reports of abuse or neglect. Roundup must request an employee to provide more detailed information regarding any findings. Employees with confirmed reports of abuse or neglect may be terminated immediately.
In acknowledgment of your understanding of the above, please sign and date the following statement.
I, the undersigned, understand that fingerprinting, a criminal record check, and a check of the Central Registry of Child Protection are conditions of employment at Roundup Fellowship. I have not been convicted or entered into a deferred judgment agreement for any of the crimes listed above. I understand that if I am found to have a criminal record or a confirmed report of abuse or neglect, my employment may be terminated immediately.
Signature_______________________________________________________________Date____________
CURRENT COSTS FOR CBI/FBI, EFFECTIVE 7-1-03
CBI Name Check Only = $6.85
Fingerprints = $5-20/card
CBI Check = $17.50
CBI + FBI check = $39.50
* An FBI check is required for all employees in the Children’s Division who have not lived in Colorado continuously for the past 24 months.
Note: The full cost of the CBI or CBI/FBI check will be deducted from your first paycheck unless you make other arrangements with the Executive Director. You will be reimbursed for this amount after completing 6 months employment.
ROUNDUP FELLOWSHIP APPLICATION QUESTIONNAIRE
1. Please rank the following from most important to least important (#1 being the most and 5 the least):
A. Distance to work _____
B. Hours _____
C. Job Duties _____
D. Pay _____
E. Work Environment _____
2. You and Karen go to McDonald’s for your weekly outing. This week Karen decides she wants a shake instead of a Diet Coke. Since she is on a diet, you tell her she can only have the Diet Coke. She starts screaming, hitting you and falls to the floor.
a. What would be your immediate intervention?
b. What type of behavioral program would you suggest to decrease or eliminate her screaming, hitting and falling behaviors?
3. How would you go about structuring three hours of free time if there were no monies available for an activity?
LIABILITY RELEASE
TO WHOM IT MAY CONCERN:
As an applicant for employment with Roundup Fellowship, I understand that a thorough background investigation will be conducted to qualify me for eligibility.
“I hereby authorize the custodian of any information related to my previous employment, driving record, education, residence, criminal convictions, credit standing, or character, to release said information to the person or agency identified herein, unless restricted by law. This authorization is made voluntarily, for the purpose of employment only. Upon receipt of this document, please release information directly related to the categories shown, and to which you have direct knowledge or documented evidence. I agree to hold harmless any individual or agency involved with the authorized release of legitimate information. Thank you for your cooperation.
Authorized by:______________________________________
Full Name, Print or Type
_______________________________________
Current Address
_______________________________________
City, State, Zip Code
_______________________________________
Telephone Number
_______________________________________
Date of Birth
_______________________________________
Social Security Number
_______________________________________
Drivers License #, State of Issue
_______________________________ ___________________________________
Company/Agency Requesting Info. Applicant Signature
_______________________________ ___________________________________
Authorized Signature, Title Date
