Employment Application Form Step 1 of 10 10% Which program are you applying for?* Supported Independent Living (SIL) Title XIX Community Homes Either Were you referred by anyone?*YesNoBy who?*Have you ever worked for Crossroads or Job link before?*YesNoDate* 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you lived there?*Social Security No.*Contact Number HomeContact Number Cell*Drivers License/State ID Number*Position Applied For:*Salary Desired:*Employment desired:*Full time onlyPart time onlyFull or part timeHow 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*WestbankEastbankWest or EastbankHave you ever been convicted of a crime?*YesNoIf 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 fieldType of School* GED High School College Business or Trade School Professional School Other: None of the Above OtherHigh School detailsName of School*Location (Full Mailing Address)*Number of years completed*Year Diploma Received*Major or type of Degree*College detailsName of School*Location (Full Mailing Address)*Numbers of years completed*Year Diploma Received*Major or type of Degree*Business or Trade School detailsName of School*Location (Full Mailing Address)*Number of years completed*Year Diploma Received*Major or type of Degree*Professional School detailsName 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?*YesNoPlease explain* ADDITIONAL WORK/EMPLOYMENT SKILLS Typing*YesNoWords per Minute*Personal Computer*YesNoPlease choose from the following*PCMac10 Key*YesNoWord Processing*YesNoWords per Minute*Other: TRANSPORTATION Do you have reliable transportation to work*YesNoWhat is/will be your means of transportation to work?*Driver's License Number:Expiration Date:State of Issue:Type of LicenseOperatorCommercial (CDL)ChauffeurNumber of accidents during the last 3 years? If so please explainNumber 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 processSignature*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 DeparmentSignature*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 AliasDate of Birth* Date Format: MM slash DD slash YYYY Social Security Number*Current Address*City*State*Zip*RaceGenderDriver's License Number*State Issued*Signature*Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.