City: State: Zip: Type of work desired: Full-Time Part-Time Temporary Foster Parent Volunteer Position(s) applied for:

Transcription

1 Emplyment Applicatin Fster Parent Applicatin Vlunteer Applicatin Name: Primary phne number: Date: Alternate phne number: address: Type f wrk desired: Full-Time Part-Time Temprary Fster Parent Vlunteer Psitin(s) applied fr: Desired salary range: * Earliest start date: Have yu submitted an applicatin here befre? Yes N If yes, give date(s): Have yu been an emplyee, fster parent, r vlunteer here befre? Yes N If yes, give dates: D yu have any relatives wh are currently an emplyee, fster parent, r vlunteer here? Yes N If yes, prvide their name(s): Prf f identity and legal authrity t wrk in the United States will be required upn engagement. Are yu legally eligible fr emplyment in the United States? * Yes N Are yu 8 years f age r lder (r if Huseparent r Family Teacher psitin)? Yes N Wuld yu be able t perfrm, with r withut reasnable accmmdatin, the essential functins f the psitin(s) fr which yu are applying? Yes N Wuld yu be able t meet the attendance requirements f the psitin(s)? Yes N Criminal histry, child abuse and neglect registry, and, if applicable, mtr vehicle recrd searches will be cnducted n yu. Have yu ever been cnvicted f r pled guilty r n cntest t a crime (excluding minr traffic vilatins)? Answering yes will nt autmatically disqualify yu. Yes N If yes, please explain ffense(s), jurisdictin(s), and final dispsitin(s): What is yur educatinal backgrund? High Schl (include city and state): Did yu graduate? Yes N Number f years cmpleted: Schl (include city and state): Did yu graduate? Yes N Degree received: Number f years cmpleted: Curse f study: 3 Schl (include city and state): Did yu graduate? Yes N Degree received: Number f years cmpleted: Curse f study: * applicants fr emplyment nly Emplyment / Fster Parent / Vlunteer Applicatin (Nvember 006) Page f 4

2 Starting with yur mst recent emplyer, prvide the fllwing infrmatin fr all emplyment since high schl r during at least the last 0 years. Indicate if yu were emplyed under a different name. Emplyer: Jb title(s) and wrk perfrmed: Supervisr: Starting pay: Reasn fr leaving: Emplyer: Jb title(s) and wrk perfrmed: Final pay: Supervisr: Starting pay: Reasn fr leaving: 3 Emplyer: Jb title(s) and wrk perfrmed: Final pay: Supervisr: Starting pay: Reasn fr leaving: 4 Emplyer: Jb title(s) and wrk perfrmed: Final pay: Supervisr: Starting pay: Reasn fr leaving: Final pay: Accunt fr any time that yu were nt emplyed since leaving schl and between psitins during at least the last 0 years. Describe yur activities: Describe yur activities: Emplyment / Fster Parent / Vlunteer Applicatin (Nvember 006) Page f 4

3 List any emplyers that yu d nt want us t cntact fr a reference and explain why: Have yu ever been discharged by a cmpany r resigned under threat f discharge? Yes N If yes, give cmpany name(s) and reasn(s) fr discharge: D yu have a valid driver license? Yes N If yes, which state? Are yu bilingual? Yes N If yes, what languages? Summarize any training, skills, licenses, and/r certificates that may qualify yu fr the psitin(s): Wrd Excel Access PwerPint Outlk Internet Describe business and civic activities and any ffices yu hld r have held: (PCHAS) is a religius rganizatin affiliated with the Presbyterian Church (U.S.A.) and prefers t emply individuals wh are Christians and wh pssess a Christian cmmitment, as well as cncern, fr children and families in need. PCHAS indicates a preference based upn religin because it is a bna fide ccupatinal qualificatin fr the jb. Please state yur religin and the cmmunity f faith in which yu are a member: Answer the fllwing questins if the psitin(s) fr which yu are applying invlve(s) cntact with children: Why d yu want t wrk with children? With what age grup and gender d yu prefer t wrk? Why? 3 Describe the three greatest strengths r assets yu have in wrking with children: 4 Describe the three mst serius weaknesses r prblems yu have in wrking with children: Emplyment / Fster Parent / Vlunteer Applicatin (Nvember 006) Page 3 f 4

4 Hw did yu hear abut the psitin(s)? What led yu t apply? Please prvide three persnal references: Name: Relatinship t applicant: Number f years knwn: Name: Relatinship t applicant: Number f years knwn: 3 Name: Relatinship t applicant: Number f years knwn: Certificatin. I certify that all infrmatin prvided by me t apply fr wrk (whether as an emplyee, fster parent, r vlunteer) with PCHAS is true and cmplete. False, misrepresented, r incmplete infrmatin f any kind will be sufficient cause fr my applicatin t be rejected r, if discvered after I begin wrk, cause fr immediate terminatin. Authrizatin. I authrize PCHAS t cntact and btain infrmatin abut me frm my previus emplyers, educatinal institutins, and references, and any ther persn r rganizatin wh may have infrmatin abut me. I waive all rights and claims I may have against PCHAS and its representatives fr seeking and using such infrmatin and all ther persns r rganizatins fr furnishing such infrmatin abut me. Discriminatin. I understand that PCHAS des nt unlawfully discriminate in emplyment, and n questin n this applicatin is used fr the purpse f limiting r excluding any applicant frm cnsideratin fr emplyment n a basis prhibited by applicable lcal, state, r federal law. Cnditins f Offer. I understand that any ffer f wrk is cnditinal upn: () the results f PCHAS' criminal histry, child abuse and neglect registry, and, if applicable, mtr vehicle recrd searches n me; () the results f my pre-wrk drug test; (3) the results f my tuberculsis test; and (4) my presenting a valid Texas driver license within 30 days. If hired, I agree t cmply with all applicable laws and all PCHAS plicies and prcedures. PCHAS prhibits abuse and neglect f the children and families it serves. At-Will Status. This applicatin is nt an emplyment, fster parent, r vlunteer agreement. If I accept an ffer f wrk, I understand that an emplyment, fster parent, r vlunteer relatinship with PCHAS is n an at-will basis. Accrdingly, either I r PCHAS may terminate the relatinship at any time, with r withut ntice and with r withut cause. I understand that n ne ther than the President and Vice President fr Administratin has authrity t enter int any agreement with terms cntrary t the freging, and then nly in writing signed by such fficer. Reapplicatin. I understand that this applicatin remains current fr 6 mnths. At the cnclusin f that time, if I have nt heard frm PCHAS and still wish t be cnsidered fr wrk, I must reapply and cmplete a new applicatin. Signature: Emplyment / Fster Parent / Vlunteer Applicatin (Nvember 006) Page 4 f 4 Date:

5 Criminal Histry Affidavit (must be signed befre a Ntary Public) An applicant fr temprary r permanent emplyment with a licensed facility r registered family hme whse emplyment r ptential emplyment with the facility r hme invlves direct interactins with r the pprtunity t interact and assciate with children must execute and submit the fllwing affidavit with the applicatin fr emplyment. The failure r refusal f the applicant t sign r prvide the affidavit cnstitutes gd cause fr refusal t hire the applicant. Tex.Hum.Res.Cde STATE OF COUNTY OF I swear r affirm under penalty f perjury that I d nt nw and I have nt at any time, either as an adult r as a juvenile:. Been cnvicted f;. Pleaded guilty t (whether r nt resulting in a cnvictin); 3. Pleaded nl cntendere r n cntest t; 4. Admitted; 5. Had any judgment r rder rendered against me (whether by default r therwise); 6. Entered int any settlement f an actin r claim f; 7. Had any license, certificatin, emplyment, r vlunteer psitin suspended, revked, terminated, r adversely affected because f; 8. Resigned under threat f terminatin f emplyment r vlunteerism fr; 9. Had a reprt f child abuse r neglect made and substantiated against me fr; r 0. Have any pending criminal charges against me in this r any ther jurisdictin fr; Any cnduct, matter, r thing (irrespective f frmal name theref) cnstituting r invlving (whether under criminal r civil law f any jurisdictin):. Any felny;. Rape r ther sexual assault; 3. Physical, sexual, emtinal abuse and/r neglect f a minr; 4. Incest; 5. Explitatin, including sexual, f a minr; 6. Sexual miscnduct with a minr; 7. Mlestatin f a child; 8. Lewdness r indecent expsure; 9. Lewd and lascivius behavir; 0. Obscene r prngraphic literature, phtgraphs, r vides;. Assault, battery, r any vilent ffense invlving a minr;. Endangerment f a child; 3. Any misdemeanr r ther ffense classificatin invlving a minr r t which a minr was a witness; 4. Unfitness as a parent r custdian; 5. Remving children frm a state r cncealing children in vilatin f a curt rder; 6. Restrictins r limitatins n cntact r visitatin with children r minrs resulting frm a curt rder prtecting a child r minr frm abuse, neglect, r explitatin; r 7. Any type f child abductin. Except the fllwing (list all incidents, lcatin, descriptin, and date) (if nne, write NONE): Criminal Histry Affidavit (Nvember 006) Signature: Printed Name: Subscribed and swrn t (r affirmed) befre me this day f,. Seal Ntary Public Signature: Ntary Public Name: My Cmmissin Expires:

6 Backgrund Check Ntificatin and Authrizatin Answer all questins. Write "Nne" if necessary. Return a cpy f yur Scial Security Card and Driver License with this frm. Ntificatin t Emplyees, Vlunteers, Fster Parents, Husehld Members, and Subcntractrs. If yu are a ptential r current emplyee, vlunteer, fster parent, husehld member, r subcntractr, this is t infrm yu that criminal histry and child abuse and neglect registry infrmatin is being btained thrugh the Texas Department f Public Safety, the Texas Department f Family and Prtective Services, and/r the Natinal Crime Infrmatin Center fr the purpse f evaluating yu. This infrmatin may be btained at any time during the applicatin prcess r during yur nging relatinship with Presbyterian Children's Hmes and Services (PCHAS). Additinal Ntificatin t Emplyees and Vlunteers. If yu are a ptential r current emplyee r vlunteer, this is t infrm yu that a cnsumer reprt r an investigative cnsumer reprt is being btained frm a cnsumer reprting agency fr the purpse f evaluating yu fr emplyment, prmtin, reassignment, r retentin as an emplyee r vlunteer. A cnsumer reprt r an investigative cnsumer reprt may be btained at any time during the applicatin prcess r during yur emplyment r vlunteer relatinship with PCHAS. The cnsumer reprt btained may include, amng ther items, criminal histry infrmatin, mtr vehicle recrd infrmatin, cnfirmatin f yur previus addresses, cnfirmatin f yur educatinal and emplyment histry, cnfirmatin f any references prvided, and infrmatin as t yur character, general reputatin, persnal characteristics, and mde f living. Authrizatin. I hereby authrize and request any present r frmer emplyer, schl, law enfrcement agency, curt, gvernmental agency, financial institutin r credit agency (if an emplyee r vlunteer), r ther persns r entities having persnal knwledge abut me, t furnish PCHAS with any and all infrmatin in their pssessin regarding me in cnnectin with any current r future emplyment, vlunteer, fster parent, husehld member, r subcntractr relatinship I have r may have with PCHAS. I specifically waive any written ntice frm any present r frmer emplyer r ther persn r entity wh may prvide infrmatin based upn this authrized request. A phtcpy f this authrizatin may be accepted in lieu f the riginal. I understand that this authrizatin will be part f my file with PCHAS. I certify that the identifying infrmatin prvided belw is true and cmplete. I have received a cpy f "A Summary f Yur Rights Under the Fair Credit Reprting Act." First Name: Middle Name: Last Name: Suffix: Scial Security Number: Date f Birth: Gender: Male Female ID Type: Driver License Identificatin Card ID Number: State: Name as it appears n Driver License r Identificatin Card: Current Street Address: Phne Number: City: Cunty: State: Zip: All Other Cities f Residence in Texas: Previus Address(es) Outside f Texas (including the cunty) in the Last 5 Years: Ethnicity (must accmpany race): Hispanic Nt Hispanic Race: American Indian / Alaskan Native Asian Black Native Hawaiian / Pacific Islander White Alternate Name(s) Used (enter all aliases, including yur maiden name, if applicable): First Name: Middle Name: Last Name: Suffix: First Name: Middle Name: Last Name: Suffix: First Name: Middle Name: Last Name: Suffix: Backgrund Check Ntificatin and Authrizatin (January 0) Signature: Date:

7 A Summary f Yur Rights Under the Fair Credit Reprting Act The federal Fair Credit Reprting Act (FCRA) prmtes the accuracy, fairness, and privacy f infrmatin in the files f cnsumer reprting agencies. There are many types f cnsumer reprting agencies, including credit bureaus and specialty agencies (such as agencies that sell infrmatin abut check writing histries, medical recrds, and rental histry recrds). Here is a summary f yur majr rights under the FCRA. Fr mre infrmatin, including infrmatin abut additinal rights, g t r write t: Cnsumer Respnse Center, Rm 30-A, Federal Trade Cmmissin, 600 Pennsylvania Ave. N.W., Washingtn, D.C Yu must be tld if infrmatin in yur file has been used against yu. Anyne wh uses a credit reprt r anther type f cnsumer reprt t deny yur applicatin fr credit, insurance, r emplyment r t take anther adverse actin against yu must tell yu, and must give yu the name, address, and phne number f the agency that prvided the infrmatin. Yu have the right t knw what is in yur file. Yu may request and btain all the infrmatin abut yu in the files f a cnsumer reprting agency (yur "file disclsure"). Yu will be required t prvide prper identificatin, which may include yur Scial Security Number. In many cases, the disclsure will be free. Yu are entitled t a free file disclsure if: a persn has taken adverse actin against yu because f infrmatin in yur credit reprt; yu are the victim f identify theft and place a fraud alert in yur file; yur file cntains inaccurate infrmatin as a result f fraud; yu are n public assistance; yu are unemplyed but expect t apply fr emplyment within 60 days. In additin, by September 005 all cnsumers will be entitled t ne free disclsure every mnths upn request frm each natinwide credit bureau and frm natinwide specialty cnsumer reprting agencies. See fr additinal infrmatin. Yu have the right t ask fr a credit scre. Credit scres are numerical summaries f yur creditwrthiness based n infrmatin frm credit bureaus. Yu may request a credit scre frm cnsumer reprting agencies that create scres r distribute scres used in residential real prperty lans, but yu will have t pay fr it. In sme mrtgage transactins, yu will receive credit scre infrmatin fr free frm the mrtgage lender. Yu have the right t dispute incmplete r inaccurate infrmatin. If yu identify infrmatin in yur file that is incmplete r inaccurate, and reprt it t the cnsumer reprting agency, the agency must investigate unless yur dispute is frivlus. See fr an explanatin f dispute prcedures. Cnsumer reprting agencies must crrect r delete inaccurate, incmplete, r unverifiable infrmatin. Inaccurate, incmplete r unverifiable infrmatin must be remved r crrected, usually within 30 days. Hwever, a cnsumer reprting agency may cntinue t reprt infrmatin it has verified as accurate. Cnsumer reprting agencies may nt reprt utdated negative infrmatin. In mst cases, a cnsumer reprting agency may nt reprt negative infrmatin that is mre than seven years ld, r bankruptcies that are mre than 0 years ld. Access t yur file is limited. A cnsumer reprting agency may prvide infrmatin abut yu nly t peple with a valid need usually t cnsider an applicatin with a creditr, insurer, emplyer, landlrd, r ther business. The FCRA specifies thse with a valid need fr access. Yu must give yur cnsent fr reprts t be prvided t emplyers. A cnsumer reprting agency may nt give ut infrmatin abut yu t yur emplyer, r a ptential emplyer, withut yur written Backgrund Check Ntificatin and Authrizatin (July 008) Page f 3

8 cnsent given t the emplyer. Written cnsent generally is nt required in the trucking industry. Fr mre infrmatin, g t Yu may limit "prescreened" ffers f credit and insurance yu get based n infrmatin in yur credit reprt. Unslicited "prescreened" ffers fr credit and insurance must include a tll-free phne number yu can call if yu chse t remve yur name and address frm the lists these ffers are based n. Yu may pt-ut with the natinwide credit bureaus at OPTOUT ( ). Yu may seek damages frm vilatrs. If a cnsumer reprting agency, r, in sme cases, a user f cnsumer reprts r a furnisher f infrmatin t a cnsumer reprting agency vilates the FCRA, yu may be able t sue in state r federal curt. Identity theft victims and active duty military persnnel have additinal rights. Fr mre infrmatin, visit States may enfrce the FCRA, and many states have their wn cnsumer reprting laws. In sme cases, yu may have mre rights under state law. Fr mre infrmatin, cntact yur state r lcal cnsumer prtectin agency r yur state Attrney General. Federal enfrcers are: TYPE OF BUSINESS: Cnsumer reprting agencies, creditrs and thers nt listed belw Natinal banks, federal branches/agencies f freign banks (wrd "Natinal" r initials "N.A." appear in r after bank's name) Federal Reserve System member banks (except natinal banks, and federal branches/agencies f freign banks) Savings assciatins and federally chartered savings banks (wrd "Federal" r initials "F.S.B." appear in federal institutin's name) Federal credit unins (wrds "Federal Credit Unin" appear in institutin's name) State-chartered banks that are nt members f the Federal Reserve System Air, surface, r rail cmmn carriers regulated by frmer Civil Aernautics Bard r Interstate Cmmerce Cmmissin Activities subject t the Packers and Stckyards Act, 9 CONTACT: Federal Trade Cmmissin Cnsumer Respnse Center FCRA Washingtn, DC Office f the Cmptrller f the Currency Cmpliance Management, Mail Stp 6-6 Washingtn, DC Federal Reserve Bard Divisin f Cnsumer & Cmmunity Affairs Washingtn, DC Office f Thrift Supervisin Cnsumer Cmplaints Washingtn, DC Natinal Credit Unin Administratin 775 Duke Street Alexandria, VA Federal Depsit Insurance Crpratin Cnsumer Respnse Center 345 Grand Avenue, Suite 00 Kansas City, Missuri Department f Transprtatin Office f Financial Management Washingtn, DC Department f Agriculture Office f Deputy Administratr GIPSA Washingtn, DC Backgrund Check Ntificatin and Authrizatin (July 008) Page 3 f 3