Job Application: Areas Corrdinator

Title: Areas Corrdinator

Fields marked with an asterisk (*) must be filled out before submitting.

Personal Details

First Name
Last Name
Email Address

Contact Details

Address
City
Post code
Telephone
SSN#

Drivers License #

Any Other Name You Are Known By
 
Employment Desired Permanent Full-time
Permanent Part-time
Temporary Full-time
Temporary Part-time
 
Position Applying for Associate Professional (must have a 4 year degree)
Qualified Professional (must have a 4 year degree with 4/2/1 years exp. with mental health population)
Paraprofessional (must have a high school diploma)
Other (office assistant, clerical, etc)
Earliest Date available to begin work
Salary Desired
Have you ever worked for the company? Yes
No
 

Education

High School (name and address)
Dates Attended
Degree Recieved
College (name and address)
Dates Attended
Degree Recieved
Graduate (name and address)
Dates Attended
Degree Recieved
 
Special Training of Volunteer word recieved in the area of employment desired
Have you ever been convicted of a Felony Yes
No
Describe (if you answered yes to above)
Have you lived outside of the state of NC in the past 5 years Yes
No
If yes, where
 

Employment History

Company Name
Phone Number
Contact Name
Phone Number
Employed From and to (dates)
Salary Paid
Position Held
Last Worked
Describe the job performed
Population Served MH
DD
SA
Child
Adult
Reason for Leaving
 
Company Name
Phone Number
Contact Name
Phone Number
Employed From and to (dates)
Salary Paid
Position Held
Last Worked
Describe the job performed
Population Served MH
DD
SA
Child
Adult
Reason for Leaving
 
Company Name
Phone Number
Contact Name
Phone Number
Employed From and to (dates)
Salary Paid
Position Held
Last Worked
Describe the job performed
Population Served MH
DD
SA
Child
Adult
Reason for Leaving
 

References

Name
Address
Phone Number
Relationship
Years Known
 
Name
Address
Phone Number
Relationship
Years Known
 
Name
Address
Phone Number
Relationship
Years Known
 

COMMUNITY HELPS NETWORK LLC. (CHN)/PATRIOT SERVICES, is an Equal Opportunity Employer and selects employees based on merti, qualifications, and abilities. CHN does not discriminate on employment oppotunities or practices on the basis of race, color, religion, gender, marital status, national orgin, age, physical or mental handicap, or status as a Vietname era or special disabled veteran, or any other characteristic protected by law.

I understand and agree that any material misrepresentation or omission of fact in my application will render this application void and may result in refusal to employ me or, if hired, termination of my employment.

I authorize CHN to investigate my work history, to verify all data given in my application for employment, related documents, or interviews, and to contact my former employers, references, reporting agencies, and any other persons. I recognize and acknowledge that any such information may be the basis for declining the employment applied for or, if hired, for termination the employment. I request and authorize all persons so contacted to furnish the information so requested and, in consideration for so doing, hereby release any persons furnishing or recieving such information for all liability wich might arise out of the communication so made or the information so furnished.

I agree that, if given a conditional offer of empolyment, I will provide, and authorize any physician or hospital to release, any information which may be necessary to dtermining my ability to perform the duties of the job for which I have been offered empoyment.

I agree to take a medical examination by a qualified physician at the discretion of CHN, after a conditional offer of employment has been made by CHN.

I understand and agree that any employment offered pursuant to this application will be at-will, terminable by either party at any time with or without reason with or without nitice, and with or without procedural formality or progressive discipline. I understand and agree that no representation, written or oral, express or implied, including without limitation those contained in any employment manuals, handbooks or information booklet that may be distributed to me during the course of my employment, shall from a contract between me and CHN so as to alter the at-will character of my employment. I further understand and agree that no person at CHN, other than the President, has any authority to make any promise or represenattion to alter the at-will character of my employment.

I understand and agree that, if offered employment, such employment shall be subject to the resonable rules and regulations of CHN as issued at any time, withouth notification.

I understand that upon acceptance of employment, I will be required to provide direct care services to my consumer(s) in the home and.or in the community for the hours that I am assigned. I understand and agree that in the event that a charge to my schedule is necessary once an assignment has been accepted, I must contact my immediate supervisor to request a change in assignment or a schdule modification. *Failure to do so may result in immediate termination.

I also understand that as part of Community Helps Network ongoing commitment to quality assurance and quality care, my consumer(s) may be contacted on a weekly basis to verify that direct care services have been recieved as scheduled and agreed to by the consumer and the direct care staff.

I understand and agree that Chn may at times require overtime, holiday work, change of hours and/or days I am scheduled to work, or require me to work a schedule other than that for which I was originally hired, and I accept these conditions of my continuing employment.

I understand and agree that CHN amy change my job title, assigned duties, wages, benefits, place of employment, and/or other conditions fo employment at any time, and I accept these as conditions of my continuing employment.

I understand and agree that this is a application for employment, and that no employment contract is offered or implied.

Signature
Date
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