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Child and Family Agency

Child and Family Agency

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Application for Employment

Step 1 of 6 - Applicant Information

16%

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

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How did you learn about us?(Required)
Name(Required)
Address(Required)
If you are under 18 years of age, can you provide required proof of your eligibility to work?(Required)
Have you ever filed an application with us before?(Required)
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Approximate date is acceptable
Have you ever been employed with us before?(Required)
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Are you currently employed?(Required)
May we contact your present employer?(Required)
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
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Available to work(Required)
Are you currently on “lay-off” status and subject to recall?(Required)
Can you travel if a job requires it?(Required)

Education and Skills

High school

Complete or partial undgraduate college?

Undergraduate College

Complete or partial Graduate college?

Graduate College

Other education

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
 
Describe any specialized training, apprenticeship, equipment skills, or other special skills.
Describe any job-related training received in the United States military.
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.

Employment Experience

Start with your present or last job. Include any job-related military assignments and volunteer activities. 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.

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Include a second employer?

Employer 2

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Include a third employer?

Employer 3

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Include a fourth employer?

Employer 4

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References

Reference 1 relationship type
Include a second reference?

Reference 2

Reference 2 relationship type
Include a third reference?

Reference 3

Reference 3 relationship type
Include a fourth reference?

Reference 4

Reference 4 relationship type

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.

Type name
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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.

Employment Data Record

Employees are treated during employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

As an employer with Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.

The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a Confidential File and are not a part of your Application for Employment or personnel file. Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

Voluntary Survey

Government agencies at times require periodic reports on the sex, ethnicity, handicap, veteran and other protected status of employees. This data is for statistical analysis with respect to the success of the Affirmative Action program. COMPLETION OF THIS INFORMATION IS OPTIONAL AND VOLUNTARY.

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Name
Address
Gender

Primary ethnic origin

Other status
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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:

  1. Under CT law employers may not require disclosure of an arrest, criminal charge or conviction for which records have been erased;
  2. 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;
  3. 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)

If you answered Yes above, please indicate below:

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

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.

Type name
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