Crossroads Louisiana, Inc.
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Employment Application Form

"*" indicates required fields

Step 1 of 6

16%
APPLICANT MAY BE TESTED FOR ILLEGAL DRUGS
Which Program are you applying for?
Have you ever worked for Crossroads or Job link before?*
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Name*
Current Address*
Are you vaccinated against COVID-19?*
Will you be able to provide a copy of your vaccination card?*
Phone Number(s):*
Days and times available to work (PLEASE CHECK ALL THAT APPLY):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Where in the GNO can you work?*
Have you ever been convicted of a crime?*
TRANSPORTATION
Do you have reliable transportation to work?*
Do you have a driver’s license?*
What type of license?*
EDUCATIONAL INFORMATION
Do you have a high school diploma?*
Do you have a GED?*
Will you agree to take a basic competency reading/writing quiz?*
REFERENCES
Please 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?*
(Reference checks with be conducted legally and in an ethical manner. All information derived will remain confidential.)
Name*

Name*

Name*

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.

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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.
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This field is for validation purposes and should be left unchanged.

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Crossroads Louisiana

Crossroads Louisiana, a 501 (c)3 non-profit agency, was founded by Dr. Gerald Murphy in 1982 to serve persons with intellectual disabilities (ID) in the Greater New Orleans area. As more and more State institutions began to shut their doors, Dr. Murphy saw an urgent need to provide community-based services that maximize each individual’s potential for independent community living and self sufficiency.

 

Contact Information

3727 General DeGaulle New Orleans, LA 70114

504-366-1828

504-366-0727

info@crossroadslouisiana.org

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