Apply online | Crossroads Louisiana, Inc.

Which program are you applying for?*
- Supported Independent Living (SIL)
- Title XIX Community Homes
- Either
Were you referred by anyone?*
- Yes
- No
By who?*
Have you ever worked for Crossroads or Job link before?*
- Yes
- No
Date*
Date Format: MM slash DD slash YYYY
Name*
First Middle Last Maiden
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Race*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
How long have you lived there?*
Social Security No.*
Contact Number Home
Contact Number Cell*
Drivers License/State ID Number*
Position Applied For:*
Salary Desired:*
Employment desired:*
- Full time only
- Part time only
- Full or part time
How many hours are you available to work weekly?*
How soon are you available for work?*
Days and times available to work (PLEASE CHECK ALL THAT APPLY):
Sunday
- Day
- Eve
- Night
Monday
- Day
- Eve
- Night
Tuesday
- Day
- Eve
- Night
Wednesday
- Day
- Eve
- Night
Thursday
- Day
- Eve
- Night
Friday
- Day
- Eve
- Night
Saturday
- Day
- Eve
- Night
Bank*
- Westbank
- Eastbank
- West or Eastbank
Have you ever been convicted of a crime?*
- Yes
- No
If yes, please explain number of convistion(s), nature of offenses(s), leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed:

EDUCATIONAL INFORMATION

Position requires High School Diploma, GED or 5 years experience in the field
Type of School*
- GED
- High School
- College
- Business or Trade School
- Professional School
- Other:
- None of the Above
Other
High School details
Name of School*
Location (Full Mailing Address)*
Number of years completed*
Year Diploma Received*
Major or type of Degree*
College details
Name of School*
Location (Full Mailing Address)*
Numbers of years completed*
Year Diploma Received*
Major or type of Degree*
Business or Trade School details
Name of School*
Location (Full Mailing Address)*
Number of years completed*
Year Diploma Received*
Major or type of Degree*
Professional School details
Name of School*
Location (Full Mailing Address)*
Number of years completed*
Year Diploma Received*
Major or type of Degree*
Other education details

Employment History

Please begin with your most recent jobs and list all jobs you have held.

NOTE: If you have previously worked for either of our companies, be sure to provide that information below.
Company Name and Address:
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Supervisor (Name and Title)
Reason for leaving:
Position title and major job duties:
Company Name and Address:
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Supervisor (Name and Title)
Reason for leaving:
Position title and major job duties:
Company Name and Address:
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Supervisor (Name and Title)
Reason for leaving:
Position title and major job duties:
Company Name and Address:
From Date
Date Format: MM slash DD slash YYYY
To Date
Date Format: MM slash DD slash YYYY
Supervisor (Name and Title)
Reason for leaving:
Position title and major job duties:

YOU MUST COMPLETE THE FOLLOWING

Crossroads Louisiana, Inc. is a progressive agency. We strive to emphasize each person’s abilities (not disabilities). We believe that each person we support is a unique individual with his/her own skills, interests, talents and resources. We believe that with support, every adult we serve is able to successfully live in the community.

In 150 words or less, tell us below, how your unique talents and abilities can help us support the people we serve.
*

EMPLOYMENT INFORMATION
Have you ever been fired/terminated from any job(s) or resigned from any job in lieu of termination?*
- Yes
- No
Please explain*

TRANSPORTATION
Do you have reliable transportation to work*
- Yes
- No
What is/will be your means of transportation to work?*
Driver's License Number:
Expiration Date:
State of Issue:
Type of License
- Operator
- Commercial (CDL)
- Chauffeur
Number of accidents during the last 3 years? If so please explain
Number of moving violations during the last 3 years? If so please explain

REFERENCES

Please provide the information requested below for 2 personal (friend, clergy, teachers, etc.) OR non-work/company references.

NOTE:At least one reference MUST be a work reference. Your application may not be processed until this section is completed in full.
Name*
First Last
Relationship*
Address*
Phone*
Name*
First Last
Relationship*
Address*
Phone*
The information provided in this application and on the attached Reference Check forms are accurate and complete. I understand that if it is determined that the information I have provided is misleading, inaccurate, false or incomplete, I will not be hired. I further understand that my employment may be terminated if it is determined, after I am hired, that the information provided on this application is misleading, inaccurate, false or incomplete.

If I'm offered a job with the Company, I understand that my employment will be at will and that no one has the right or authority to offer me employment for a definite term or duration.

The Company is an Equal Employment Opportunity employer and does not discriminate on the basis of gender, race, age, disability, national origin, religion, veteran status or any other category protected under state or federal laws.

I authorize the Company to conduct oral and/or written reference checks, Criminal Records Check, and drug testing as part of the application process
Signature*
Date*
Date Format: MM slash DD slash YYYY

To Whom It May Concern:

I have applied for a job with Crossroads Louisiana, Inc. /Job Link Your cooperation in supplying Crossroads and/or Lob Link with the information requested below concerning my work record at your company would be greatly appreciated. I hereby release you and the company providing responses below from any and all claims of any type which I may or might have arising out of your completing this reference check form. My signature below is my authorization to release the information requested. Thank you in advance for your assistance in this matter.

CRIMINAL RECORD CHECK FEE: As of July 1, 2013, the fee for Criminal Background Ckecjk is $46.00. This is authorization to deduct that amount from my paycheck following being hired.

From: Crossroads La Inc. / Job Link Human Resources Deparment
Signature*
Date*
Date Format: MM slash DD slash YYYY
Applicants Social Security Number*

State Police Inquiry Authorization and Release

In connection and for the duration (including contract for services) with Crossroads Louisiana, Inc./lob Link, Inc. , I understand that I am selecting to provide requested personal information to process a background and security check as a condition for potential employment. Background Research Solutions, LLC "BRS", an authorized agency, will obtain an investigative report maintained in the files of the Louisiana Bureau of Criminal Identification and Information within the Department of Public Safety and Corrections pursuant to LA R.S. 40:1203.2. Reported information will be in compliance with subsection 0(1) which states "The office or authorized agency shall provide to the employer only such information as is necessary to specify whether or not that person has been arrested for or convicted of or pled nob contendere to any crime or crimes, the crime or crimes for which he has been arrested or convicted or to which he has pled nolo contendere, and the date or dates on which the crime or crimes occurred". Follow up investigations may be made into Louisiana parish or local court records and/or court records of another state. Further, I understand that you may request information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, medical exclusion and other experiences as well as claims involving me in the files of insurance companies.

I hereby authorize and understand such investigation and further give permission to authorized law enforcement agencies and /or courts to release all criminal record information maintained in their files which may confirm or deny my employment eligibility. ''BRS" is only disseminating information requested and is not rendering or offering opinion on employment and/or permit eligibility.

Your authorization releases Background Research Solutions, LLC an authorized agency, any law enforcement agency and/or court contracted by the authorized agency from all damages, of whatever type or nature, including court costs and reasonable attorney fees suffered by any person, including the undersigned, while investigating my criminal history.

It is my understanding that the results of the investigation will remain confidential and that if any criminal history is found to exist, then I will be provided an opportunity to refute, correct, and/or otherwise clarify such information by conducting a right to review with Louisiana Bureau of Criminal Identification and Information within the Department of Public Safety and Corrections, Office of the State Police.

I agree that any copy of this document is as valid as the original.
First, Middle and Last Name*
Maiden Name or Alias
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number*
Current Address*
City*
State*
Zip*
Race
Gender
Driver's License Number*
State Issued*
Signature*
Date*
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Employment Application Form

Step 1 of 10

Days and times available to work (PLEASE CHECK ALL THAT APPLY):

EDUCATIONAL INFORMATION

High School details

College details

Business or Trade School details

Professional School details

Other education details

Employment History

YOU MUST COMPLETE THE FOLLOWING

In 150 words or less, tell us below, how your unique talents and abilities can help us support the people we serve.

EMPLOYMENT INFORMATION

ADDITIONAL WORK/EMPLOYMENT SKILLS

TRANSPORTATION

REFERENCES

CRIMINAL RECORD CHECK FEE: As of July 1, 2013, the fee for Criminal Background Ckecjk is $46.00. This is authorization to deduct that amount from my paycheck following being hired.