Employment Application

Page 1

Family Connection SC is an at-will employer as allowed by applicable state law. Employment at-will means that regardless of any provision in this application, if hired, the company or the employee may terminate the employment relationship at any time, for any reason, with or without cause or notice.

This application form is intended for use in evaluating your qualifications for employment. All qualified applicants will receive consideration without regard to sex, race, color, age, creed, national origin, religion, disability, veteran status, uniformed service-member, genetic information, or any other category protected by applicable federal, state, or local laws, regulations or ordinances. No question on this application is intended to secure information to be used for such discrimination. Testing of job-related skills may be required prior to employment.

Name

Middle Initial

Last

What position are you applying for?

Phone Number

Alternate Phone Number

Email

Current Address

City

State

Zip Code

How long have you lived there?

Years

Months

Previous Address

City

State

Zip Code

How long have you lived there?

Years

Months

Desired Salary/ Hourly Rate

If under the age of 18, can you produce the necessary work certificate at the time of employment?

YesNoN/A

Type of employment desired?

Full-timePart-time

Specify Hours

Are you willing to work overtime?

YesNo

Date on which you can start work if hired

Have you previously applied for employment with Family Connection SC?

YesNo

If yes, when and where did you apply?

Have you ever been employed by Family Connection SC?

YesNo

If yes, provide dates of employment, location and reason for separation from employment

List all certifications or special technical skills that you feel qualify you for the job for which you are applying

Page 2

Family Connection SC is an at-will employer as allowed by applicable state law. Employment at-will means that regardless of any provision in this application, if hired, the company or the employee may terminate the employment relationship at any time, for any reason, with or without cause or notice.

Education

	School Name and Location (Address, City & State)	Course of Study	Did you Graduate?	Degree/ Major
High School
College
Business/ Technical/ Trade or Post College

Honors Received

If applicable, list below any other names by which you have been known which may be necessary to allow us to confirm your work and educational record. (For example: change of name, use of assumed name, nickname, etc.)

Page 3

Family Connection SC is an at-will employer as allowed by applicable state law. Employment at-will means that regardless of any provision in this application, if hired, the company or the employee may terminate the employment relationship at any time, for any reason, with or without cause or notice.

Work Experience

Please list the names of your present and/or previous employers in chronological order with most current or last employer listed first. Account for all periods of time including any period of unemployment. If self-employed, supply operating name and business references. You may include any verifiable work performed on a volunteer basis, internships, or military service. Failure to completely respond to each inquiry may disqualify you for consideration from employment.

Employer

Name

Type of Business

Address

Phone

Dates Employed

Job Title

Duties

Supervisors Name

May we contact?

YesNo

If no, why not?

Wages

Reason for leaving?

What will this employer say was the reason your employment was terminated?

How much notice did you give when resigning? If no notice provided, explain:

***PLEASE CHOOSE "ADD ANOTHER RESPONSE" ABOVE TO ADD ADDITIONAL EMPLOYERS

Page 4

Family Connection SC is an at-will employer as allowed by applicable state law. Employment at-will means that regardless of any provision in this application, if hired, the company or the employee may terminate the employment relationship at any time, for any reason, with or without cause or notice.

Please explain fully all gaps in your employment history in excess of one month

Have you ever been terminated or asked to resign from any job?

YesNo

Has your employment ever been terminated by mutual agreement?

YesNo

Have you ever been given the choice to resign rather than be terminated?

YesNo

If you answered yes to any of the above three questions, please explain the circumstances of each occasion

References

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

	Name	Position	Company	Work Relationship (Supervisor/ Co-worker)	Telephone/Email

Page 5

Family Connection SC is an at-will employer as allowed by applicable state law. Employment at-will means that regardless of any provision in this application, if hired, the company or the employee may terminate the employment relationship at any time, for any reason, with or without cause or notice.

APPLICATION CERTIFICATION

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate termination.

FAMILY CONNECTION SC IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.

IF HIRED, I AGREE TO CONFORM TO THE POLICIES, RULES, AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH POLICIES, RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I authorize Family Connection SC or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking and to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the required employment screening process.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to Family Connection SC or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability Family Connection SC and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information.

If hired by Family Connection SC I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand Family Connection SC employs only individuals who are legally eligible to work in the United States.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

Applicant Name

Date

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF 1 YEAR. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.