Crossnore School, Inc.
PO Box 249....100 DAR Drive
Crossnore, NC 28616
Phone: (828)733-4305
Fax: 733-3250
E-Mail: accountypay@crossnoreschool.org
Website: www.crossnoreschool.org
Crossnore School, Inc. is a residential facility fully accredited by the
Council on Accreditation of Services for Families and Children, Inc.
AN EQUAL OPPORTUNITY EMPLOYER
Crossnore School, Inc. does not discriminate in recruitment or employment on the basis of race, color, religious creed, national origin, sex, age (21 years and over), ancestry, veteran status or other protected groups under federal, state or local Equal Opportunity Laws. Crossnore School, Inc. does not discriminate against qualified individuals with disabilities. No question on this application is intended to secure information to be used for such discrimination.
(PLEASE PRINT)
NAME______________________________________________________________________________________ LAST FIRST MIDDLE
POSITION APPLIED FOR______________________________________________________________________
DATE OF APPLICATION_____________ DATE AVAILABLE FOR WORK______________________________
OFFICE USE ONLY
Date application received: ________________________Date of initial interview: __
Date of overnight interview (RC’s only): _ Date employed:
Date of resignation/termination: __Recommended by:
________________________________________________________SEX: MALE:_______ FEMALE:_______
LAST NAME FIRST MIDDLE
_______________________________________________ HOME PHONE:________________________________
ADDRESS (CITY, STATE, ZIP)
BUSINESS PHONE: SOCIAL SECURITY # _______-_______-_______
E-MAIL ADDRESS:
ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE U.S.? YES___ NO___ CITIZEN? YES___ NO___
EMERGENCY CONTACT (NAME AND PHONE NUMBER):
NAME/AGE OF DEPENDENTS (If applying as a couple): ___
SPOUSE’S NAME/OCCUPATION: __
HAVE YOU EVER BEEN CONVICTED OF CHILD ABUSE OR NEGLECT: ______NO ______YES
WILL YOU WORK OVERTIME IF ASKED: ______NO ______YES
HAVE YOU FILED AN APPLICATION AND/OR WORKED HERE BEFORE? ______NO ______YES
IF YES, GIVE DATE(S): ___
HOW DID YOU LEARN OF OUR AGENCY?
If hired, a pre-employment physical exam, TB test and drug screen are required .
HEALTH
DATE OF LAST PHYSICAL_________________________ DATE OF TB TEST______________________
ARE YOU PHYSICALLY & MENTALLY CAPABLE OF PERFORMING THE JOB WHICH YOU ARE APPLYING FOR AS DESCRIBED IN THE JOB DESCRIPTION? NO YES
Please submit copies of diplomas, degrees, certifications
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SCHOOL NAME AND LOCATION |
NUMBER OF YEARS COMPLETED |
YEAR GRADUATED |
DIPLOMA/ |
MAJOR |
High School |
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College |
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Other (specify) |
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LIST CHILD CARE, HUMAN SERVICES AND OTHER RELATED TRAINING OR SPECIAL SKILLS:_________
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EMPLOYMENT
Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer. Please complete each section even if submitting a resume. |
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1 |
_______________________________________________________________ State Job Title and Describe Your Work
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Telephone:_____________________________________ Employed: month/year Weekly/Monthly pay Reason for Leaving |
2 |
_______________________________________________________________ State Job Title and Describe Your Work
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Telephone:_____________________________________ Employed: month/year Weekly/Monthly pay Reason for Leaving |
3 |
_______________________________________________________________ State Job Title and Describe Your Work
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Telephone:_____________________________________ Employed: month/year Weekly/Monthly pay Reason for Leaving |
WE WILL CONTACT THE EMPLOYERS LISTED ABOVE UNLESS YOU INDICATE THOSE YOU DO NOT WANT US TO CONTACT. |
DO NOT CONTACT |
Employer Number(s)________________ Reason_____________________________________ _____________________________________________________________________________ |
3 non-related references are required.
NAME |
COMPLETE ADDRESS |
PHONE/FAX NUMBER |
OCCUPATION |
RELATIONSHIP/HOW LONG KNOWN? |
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MILITARY
DID YOU SERVE IN THE U.S. ARMED FORCES? ___YES ___NO |
IN WHAT BRANCH? ________________________________ DATES OF SERVICE: _______________________________ |
DESCRIBE ANY TRAINING RECEIVED RELEVANT TO THE POSITION FOR WHICH YOU ARE APPLYING ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ |
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ADDITIONAL INFORMATION
VALID DRIVER’S LICENSE: YES_______ NO_______ #: __________________ STATE:____________________
* A valid driver’s license is necessary for employment as a resident counselor.
RESTRICTIONS:________________________________________________________________________________________________
HAVE YOU HAD ANY TRAFFIC VIOLATIONS OR ACCIDENTS WITHIN THE PAST THREE YEARS? ______YES ______NO
IF “YES” PLEASE EXPLAIN:_____________________________________________________________________
HAVE YOU EVER HAD YOUR DRIVER’S LICENSE SUSPENDED OR REVOKED? _______YES ______NO
IF “YES” PLEASE EXPLAIN:_____________________________________________________________________
HAVE YOU EVER BEEN CONVICTED OF A VIOLATION OF THE LAW OTHER THAN A MINOR TRAFFIC VIOLATION?
______YES ______NO
IF “YES”, PLEASE EXPLAIN:_____________________________________________________________________
**On an attached sheet of paper, in your own handwriting, please list three values
which are important to you and give reasons why. Please limit remarks to one page.
APPLICANT’S CERTIFICATE AND RELEASE
(Read Carefully Before Signing)
All information provided by me in support of my application to for employment is true and correct to the best of my knowledge. I understand that misrepresentations or omissions may be cause for rejection, or may be cause for subsequent dismissal if I am hired.
I hereby authorize any former employer, person, firm, corporation or government agency to answer any and all questions and to release or provide any information within their knowledge or records, and I agree to hold any or all of them blameless and free of any liability for releasing any truthful information that is within their knowledge or records.
Therefore, my employment will be for no definite period and may, regardless of the date of payment of wages, be terminated at any time without previous notice and with or without reason, at the will of either myself or Crossnore School, Inc. I understand that all employees of CSI are “at will” employees. I also understand and agree that no one has authority to promise job security or continued employment, except the Executive Director of the agency in a formal written agreement signed by both of us.
Crossnore School, Inc. is hereby authorized to release to any other firm or person with whom I may seek employment any and all information concerning my employment or application.
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Signature of Applicant Date