Community Care Employment Application "*" indicates required fields Name* Date of Application* MM slash DD slash YYYY Email* Phone*Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Which Position are you applying for?* Are you 18 years of age or older?* Yes No For Shaw House/Youth Homeless Services programs only, are you 21 years of age or older?* Yes No Not Applicable When are you able to begin work?* MM slash DD slash YYYY Are you able to work:* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time* Part Time Full Time Mornings Afternoons Evenings Overnights Have you ever been employed with us before?* Yes No Have you ever filed an application with us before?* Yes No Do you have a legal right to work in the U.S.?*Proof of identity and eligibility will be required upon hire Yes No 1.Have you ever been convicted of a crime? (Includes Felony, Misdemeanor, or OUI) A conviction will not necessarily result in denial of employment*If yes, explain with dates and details below in the space provided. Yes No If you answered "yes" to Question 1 please provide details including dates below:2.Have you ever been investigated for abuse, neglect, or exploitation of a youth or vulnerable adult?*If yes, explain with dates and details below in the space provided. Yes No If you answered "yes" to Question 2 please provide details including dates below:3.Have you ever, in this state or any state, had a license or certification (e.g. driver's license, professionallicense) revoked or suspended, or have you ever voluntarily surrendered a license or certification?*If yes, explain with dates and details below in the space provided. Yes No If you answered "yes" to Question 3 please provide details including dates below:Are you able to travel if required* Yes No Can you provide transportation for self?* Yes No Can you provide transportation for clients?* Yes No Are you related to anyone who works for, or contracts with, Community Care?* Yes No if Yes, please name & relationship How did you learn about us? Indeed/Website Friend/Relative Current Employee Other Have you reviewed the essential duties of the position for the job for which you are applying?* Yes No Are you able to perform the duties of the position for which you have applied with or without accommodations?* Yes No EducationName of School(s), Grade Completed, Major/Degree*Have you completed a Bachelor's Degree? Yes No Anticipated Graduation Date MM slash DD slash YYYY Have you completed a Master's Degree? Yes No Anticipated Graduation Date MM slash DD slash YYYY Please list any professional licenses (with license number) or certifications that you currently hold(including CPR, First Aid, MHRT/C, social work licensure, clinical licensure)Professional ReferencesPlease select this if you have more professional references to submit More references Professional Reference name & title* Company they represent* Email* If you are unable to obtain an email address for a reference listed below, indicate n/a in the box.Phone #*Professional Reference name & title* Company they represent* Email* If you are unable to obtain an email address for a reference listed below, indicate n/a in the box.Phone #*Professional Reference name & title* Company they represent* Email* If you are unable to obtain an email address for a reference listed below, indicate n/a in the box.Phone #*Work ExperienceStart with the most recent position and move backward through all positions and military experience for the past 20 years, including employed months and years. Furnish dates and explanations for each period of unemployment of one month or more. You may exclude employment during high school. Please attach an additional page if necessary.Please check here if you are attaching additional pages to document work history Additional Pages Attached Employer* Address* Phone*Position* Employed From* Employed To* Responsibilities*Reason for leaving*May we contact?* Yes No Contact Person and phone number Employer Address PhonePosition Employed From Employed To ResponsibilitiesReason for leavingMay we contact? Yes No Contact Person and phone number Employer Address PhonePosition Employed From Employed To ResponsibilitiesReason for leavingMay we contact? Yes No Contact Person and phone number I hereby certify that the information on this application, on my resume, and in my interviews contains no willful misrepresentations and that the information given by me is correct, and complete to the best of my knowledge, and belief. I understand that if I am hired, any false or misleading statement, falsification, or omission of material fact, whenever or however discovered, may lead to discipline up to and including termination. I also authorize the employer to verify all statements contained in this application and to make any necessary job related reference checks. I authorize the employers, supervisors, and references provided or discovered during my application process to give any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for damage or injury that may result from furnishing this information. In consideration of my employment, I agree to the rules and regulations of the employer, and my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the employer or myself. I understand that no manger or representative of the company, other than the Executive Director, 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 understand that nothing contained in this application or that any policy, practice, or procedure of the company creates a contract between the company and me for either employment or for the providing of any benefits. I understand that an offer of employment is conditional based upon the results of a medical examination and background checks.Signature* Date* MM slash DD slash YYYY Additional InformationAdditional DocumentsUse this to upload additional documents such as Cover Letter, CV, Resume, additional References or Work Experience. Accepted file types: docx, doc, pdf, Max. file size: 32 MB.CAPTCHA