Employment Application Form "*" indicates required fields Step 1 of 6 16% Referred by:* APPLICANT MAY BE TESTED FOR ILLEGAL DRUGSWhich Program are you applying for? Job Link Day Center Supported Independent Living (SIL) Title XIX Community Homes No Preference Have you ever worked for Crossroads or Job link before?* Yes No Date* MM slash DD slash YYYY Name* First Middle Last Maiden Current Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you lived there?* Social Security No.* Are you vaccinated against COVID-19?* Yes No Will you be able to provide a copy of your vaccination card?* Yes No Phone Number(s):* Home Cell Email* Position Applied For:* Salary Desired: $* 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 Where in the GNO can you work?* Westbank Eastbank West AND/OR Eastban Have you ever been convicted of a crime?* Yes No 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: TRANSPORTATION Do you have reliable transportation to work?* Yes No What is/will be your means on transportation to work?* Do you have a driver’s license?* Yes No What type of license?* Operator Chauffeur Commercial (CDL) Issuing State:* License No.:* Exp. Date:* EDUCATIONAL INFORMATIONDo you have a high school diploma?* Yes No Do you have a GED?* Yes No Will you agree to take a basic competency reading/writing quiz?* Yes No REFERENCESPlease provide details of 3 people who may speak on your behalf regarding your work history (friends, clergy, teachers, coworkers, etc.). NO relatives. Do you agree to have references contacted in relation to this application?* Yes No (Reference checks with be conducted legally and in an ethical manner. All information derived will remain confidential.) Name* First Last Address* Phone*Relationship* Years Known* Name* First Last Address* Phone*Relationship* Years Known* Name* First Last Address* Phone*Relationship* Years Known* I acknowledge the information provided in this application and on the attached reference forms are accurate and complete. 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 checks, and drug testing as part of my application process and employment. CRIMINAL RECORD CHECK FEE: As of October 1, 2020, the fee for a criminal background check is $37.00. This is authorization to deduct that amount from my paycheck following being hired. Signature*Date* MM slash DD slash YYYY State Police Inquiry Authorization and Release n connection and for the duration (including contract for services) with Crossroads Louisiana, Inc./Job 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 D(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 nolo 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* MM slash DD slash YYYY Social Security Number* Current Address* City* State* Zip* Race Gender Driver's License Number* State Issued* Signature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
