Home Personal Information First Name Last Name Other Names Used Preferred Name Home Phone Work Phone Email Address Mailing Address City State Zip Code Upload a Resume: Include a Cover Letter: Previous Address Street Address City State Zip Code From (date) To (date) Have you ever lived outside of Vermont? Yes No Dates Where Position currently applying for? Are you available for Full-Time Work Part-Time Work Date Available Have you been employed at NCSS in the past? Yes No Dates employed Are you currently, or have you ever provided contracted services for NCSS such as: Home Provider Personal Care Attendant Companion/Respite Other If you checked other, please indicate: Dates Education Education Name & Address of School Course of Study Years Completed Graduated? Degree or Diploma College Yes No Vocational Yes No High School Yes No Elementary Yes No Other Yes No Are you legally available to work in the United States? Yes No Do you currently have a valid driver's license? Yes No Note: a "yes" answer to any of the following questions does not automatically disqualify you from employment consideration Has you driver's license been suspended or revoked in the past three years? Yes No If yes, please describe in full: Are you under a Domestic Abuse order? Yes No If yes, please describe in full: Have you ever had any professional license or credentials sanctioned, suspended, denied or revoked? Yes No If yes, please describe in full: Do you have any relatives working here? Yes No If yes, please give names: Memberships in professional or civic organizations: (exclude labor organizations and those memberships which may disclose your race, color, religion, national origin, age, disability, or other protected status) Employment — Must be completed in full Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer. 1 Company Name Address Name of Supervisor Telephone Employed From Employed To State job title and describe your work Reason for Leaving 2 Company Name Address Name of Supervisor Telephone Employed From Employed To State job title and describe your work Reason for Leaving 3 Company Name Address Name of Supervisor Telephone Employed From Employed To State job title and describe your work Reason for Leaving 4 Company Name Address Name of Supervisor Telephone Employed From Employed To State job title and describe your work Reason for Leaving 5 Company Name Address Name of Supervisor Telephone Employed From Employed To State job title and describe your work Reason for Leaving Please explain any time lapses between employment We may contact the employers listed above unless you indicate those that you do not want us to contact. Do Not Contact: Employer Name & Number: Reason: Complete this section if you served in the United States Armed Forces Describe your duties and any special training: Branch of Service Period of Active Duty (month and year) From Period of Active Duty (month and year) To Rank at Discharge Date of Final Discharge Please note: NCSS is a service provider. To avoid any actual or potential conflict of interest, NCSS prefers not to provide services for employees, their immediate families or individuals residing in the same household with employees. (Reference HR Policy 127 - Employee Use of "In-house" Clinical Services). Please be aware, NCSS does not request or require that you disclose at this time whether services are being received from NCSS. Such conflict of interest issues may be discussed at a later time, if and when a conditional offer of employment is made. As a general rule, where a person (or his or her family member, or person living in the same household) is receiving NCSS services, and then becomes an employee, we require transition to another provider as a condition of employment. For a more complete discussion of this policy, please contact the Human Resources Director at 524-6554 x6421. You will receive a confidential consultation regarding your options under HR Policy 127. Signature I certify that all information provided in this employment application is true, accurate and complete. I understand that any false or misleading information, including omission, intentional or unintentional, may disqualify me from further consideration for employment and may result in my dismissal if subsequently discovered. I also understand that any offer of employment with NCSS is conditioned upon satisfactory results of criminal and motor vehicle background checks. I further understand that acceptance of an offer of employment with NCSS does not create a guarantee of employment for a definite period of time or an obligation on NCSS’ part to continue to employ me in the future. I understand that if hired I have been hired at the will of NCSS and my employment may be terminated at anytime, with or without cause and with or without notice. By checking this box I indicate that I understand and agree to the above conditions Authorization to Check References I hereby authorize Northwestern Counseling & Support Services, Inc. (“NCSS”), or its agents/employees, to perform a check on my references and credentials, including verification of salary, degree(s), professional licenses, internship, residency, fellowship, experience, certification credentials, and any other background information, which may be requested in conjunction with my active candidacy for a position with NCSS. This check will include, but is not limited to, verbal or written communications and/or discussions with my past and/or current employer and/or supervisor(s), co-workers, friends, business associates, past and/or current educational institutions, or other individuals that NCSS, at its sole discretion, believes may have relevant information regarding my suitability for employment. I hereby agree to release and hold harmless NCSS, its agents and employees from any and all claims arising out of NCSS’ investigation of my references and credentials and any employment decisions made about me on the basis of information revealed by such investigation. I also authorize all persons, institutions, organizations, and companies to whom this Authorization to Check References is presented to release and furnish to NCSS, its employees or agents any and all employment, education, credentialing and/or any other information sought in connection with this check. I hereby release and hold harmless any person, institution, organization, or company contacted by NCSS from any and all claims arising out of the release of information to NCSS in connection with its investigation of my references and credentials. Name Professional Licensure(s) and/or Designations Highest Level of Education Completed Degree Earned Date Earned College/University Name College/University Address By checking this box I give the above authorizations References If this section is left blank, it is assumed that you can provide references upon request. #NameRelationshipEmailPhone 1 2 3 4 Submit Application
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