Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

WE ARE AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

Date of application(Required)

Position(s) applied for(Required)

How did you learn about us?(Required)

Newspaper

Employment Agency

Online Advertisement

Relative

Friend

Walk-in

CFA Employee

Other

Learned about us – Other specified(Required)

Learned about us – CFA Employee name(Required)

Whom at CFA recommended this position to you?

Applicant Information

Applicant Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mobile Phone / Primary phone(Required)

Home Phone

Email(Required)

If you are under 18 years of age, can you provide required proof of your eligibility to work?(Required)

Yes

No

Not applicable (18+ years old)

Have you ever filed an application with us before?(Required)

Yes

No

Provide date of prior application(Required)

Approximate date is acceptable

Have you ever been employed with us before?(Required)

Yes

No

Date of prior employment with us(Required)

Are you currently employed?(Required)

Yes

No

May we contact your present employer?(Required)

Yes

No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?(Required)

Proof of citizenship or immigration status will be required upon employment

Yes

No

On what date would you be available for work?(Required)

Available to work(Required)

Full time

Part time

Temporary

Evenings

Are you currently on “lay-off” status and subject to recall?(Required)

Yes

No

Can you travel if a job requires it?(Required)

Yes

No

Education and Skills

High school

High school name and address

High school course of study

High school years completed

High school diploma/degree

Complete or partial undgraduate college?

Yes

No

Undergraduate College

Undergraduate College name and address

Undergraduate College course of study

Undergraduate College years completed

Undergraduate College diploma/degree

Complete or partial Graduate college?

Yes

No

Graduate College

Graduate College name and address

Graduate College course of study

Graduate College years completed

Graduate College diploma/degree

Other education

Other education name and address of school

Other education course of study

Other education years completed

Other education diploma/degree

Indicate any foreign languages you can speak, read, and / or write

Spoken language(s)

Fluent

Good

Fair

Reading language(s)

Fluent

Good

Fair

Written language(s)

Fluent

Good

Fair

Special skills

Describe any specialized training, apprenticeship, equipment skills, or other special skills.

Military experience

Describe any job-related training received in the United States military.

Other experiences

List professional, trade, business, civic or volunteer activities, and offices held. You may exclude membership which would reveal race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Applicant’s Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed one year. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

If employed I agree to abide by the Personnel Manual, Policies and Procedures Manual and the Employee Agreement.

I understand that, if offered a position, I will provide my Social Security Number for use in employment purposes.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Any applicant who uses the Agency’s behavioral health services for him or herself or a family member will have to discontinue that use if hired. Prior or existing use of services will not affect consideration of an application for employment.

Signature of Applicant(Required)

Type name

Date of signature(Required)

Note to Applicant: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING

Are you capable of performing in a reasonable manner the activities involved in the job or occupation for which you have applied?(Required)

A description of the activities involved in such job or occupation is available upon request.

Yes

No

Criminal History Check

NOTE TO APPLICANT: A criminal background check is necessary as part of our application process.

* PLEASE NOTE WHEN ANSWERING THE FOLLOWING QUESTIONS:

Under CT law employers may not require disclosure of an arrest, criminal charge or conviction for which records have been erased;
Any person whose criminal records were erased will be considered to have never been arrested or convicted for such matter(s), and may swear so under oath concerning such erased records;
The type of criminal records subject to erasure are those pertaining to:
- a finding of delinquency of that a child was a member of a family with service needs;
- a sentence as a youthful offender;
- a criminal charge that was dismissed or nulled;
- a criminal charge for which the person was found not guilty; and
- a conviction for which the person received an absolute pardon.

Have you ever been convicted of a felony, or a sex related or child abuse related offense?(Required)

Yes

No

If you answered Yes above, please indicate below:

the date(s) of the conviction(s)
describe the circumstances and nature of the offense, and
describe what rehabilitation you have been through concerning such conviction(s)

Description of conviction(Required)

I hereby give permission for the Child and Family Agency of Southeastern CT, Inc. to conduct a criminal background check (post employment offer) for any record of a felony conviction. I agree to fully cooperate in any such background investigation, and to sign any waivers or releases that may be necessary to obtain access to relevant information. In the event that any custodian of data will not release reference information or criminal history information directly to the Company, I agree to personally request such information to the extent permitted by law. I understand that any conviction record(s) discovered during such investigation will be kept confidential and will not be disclosed to anyone except those Company personnel representatives with a need to know based on management responsibilities or involvement with the hiring process.

Background check signature(Required)

Type name

Date(Required)

Application for Employment