Flying Colors of Success, Inc. 88 East Main Street Westminster, Maryland 21157 (410) 876-0838 Employment Application We are an Equal Opportunity Employer Please read carefully, print or type clearly, and complete in full. Last Name First Name Middle Initial Social Security Number Address (Number & Street, Apartment or Box Number) City State Zip Code Phone Number (include area code) Cell Phone (include area code) Email address Are you at least 18 years old? ( ) Yes ( ) No If not, do you have a valid work permit? ( ) Yes ( ) No ( ) N/A Do you have a legal right to work in the United States? ( ) Yes ( ) No If hired, it will be necessary for you to promptly submit documentation of your identity and right to work in the U.S. Position or Type of Work Desired (in order of preference) 1. 2. 3. Seeking: Preference ( ) Full-time ( ) Part-time ( ) Substitute Shift: Available to work holidays? ( ) Yes ( ) No Available to work weekends? ( ) Every ( ) Every other ( ) Some ( ) None Date available to start: Presently employed? ( ) Yes ( ) No Rate of pay expected $ per How were you referred? Have you ever worked for F.C.S., Inc. before? ( ) Yes ( ) No If yes, when? Have you ever applied to work at F.C.S., Inc. before? ( ) Yes ( ) No If yes, when? Can you perform the functions of this job with or without reasonable accommodation? ( ) Yes ( ) No ************************************************************************************************* Military (Complete section if you served in the Armed Forces) What was your final rank? Period of active duty from to month/year month/year Describe your major duties and any special training:
What type of discharge did you receive? Education (Please complete all information that applies) Name of School City/State Major Course/Scholastic Highest Degree/or Subject Average Grade Diploma Completed High School College* (College grads. may be required to submit transcript upon hire) Graduate Work Other ************************************************************************************************* Professional Organizations: Do not list any organization that would reveal race, creed, religion, national origin, physical handicap, marital status, or ancestry. Professional Licenses/Certifications State of Issue Number Date Issued Renewal Date 1. Have you successfully completed the February 1993 Revised D.D.A. Medication Administration Training Program Curriculum? ( ) Yes ( ) No 2. Has your privilege to administer medication in a D.D.A. community provider agency ever been revoked and/or terminated? ( ) Yes ( ) No If yes, When (date) ; Where (agency) ; Delegating R.N. ; Reason. I,, authorize Flying Colors of Success, Inc. to obtain information from concerning my medication administration status. (previous employer/agency) 3. Do you have a valid Driver's license? ( ) Yes ( ) No State License No. Expiration date Restrictions No. of points ************************************************************************************************* Have you ever been convicted of any crime other than minor traffic violations? ( ) Yes ( ) No Have you ever been convicted of driving under the influence of alcohol/drugs? ( ) Yes ( ) No Do you have any convictions regarding the use, possession or sale of alcohol/drugs? ( ) Yes ( ) No
If yes, attach a full explanation of the circumstances. Please note that a conviction record will not necessarily prevent employment at Flying Colors of Success, Inc. Such factors as nature of offense and other aggravating and mitigating circumstances may be considered. Work Experience (Begin with present or most recent employer and list all prior employers. Reason for leaving must be completed for all employers.) If you worked outside of the USA, you must include that employer information as well. May we contact your past and present employers? ( ) Yes ( ) No 1. Name of Employer Complete Address (include zip code) Telephone Number From to Salary $ per ( ) Part-time ( ) Full-time Name and Title of Supervisor Your Job Title Describe your Major Duties: Reason for Leaving: 2. Name of Employer Complete Address (include zip code) Telephone Number From to Salary $ per ( ) Part-time ( ) Full-time Name and Title of Supervisor Your Job Title Describe your Major Duties: Reason for Leaving: 3. Name of Employer Complete Address (include zip code) Telephone Number From to Salary $ per ( ) Part-time ( ) Full-time Name and Title of Supervisor Your Job Title Describe your Major Duties: Reason for Leaving: If more than 3 previous employers, list all others below, another page may be added if necessary: Employment Dates Employer Name and Address Position Reason for Leaving 4._ * Please explain any gaps in employment: **********************************************************************************************************
References: (Please list only individuals familiar with your professional skills or work attitudes, do not include supervisors listed above or relatives.) Name of Reference Complete Mailing Address Telephone Number Occupation 1._ 2._ 3._ IntelliCorp Records, Inc. Criminal Background Check / Driving Record Information Sheet Social Security Number Driver s Lic.# State Date of Birth Name Other names Years used Male/Female Current Address (City, State, ZIP) (County of Residence) Email address Addresses for the Past Seven Years Dates of Residence
For Flying Colors of Success, Inc. Use Only: Date Ordered: Confirmation number: Be sure to read and sign the back of this form before returning. Pre-Employment Statement (Please read before signing) The facts set forth in my application for employment are true and complete. I understand that false statements and/or material omissions on this application may be considered cause for rejection of this application or for termination of employment. I hereby authorize Flying Colors of Success, Inc., by and through its independent contractor, IntelliCorp Records, Inc., to procure a consumer report and/or investigative consumer report on me including, work history, reference, driving record, police record inquiries, and any other public record as it deems appropriate. I also understand that continued employment may be contingent on the results of this investigation. I release Flying Colors of Success, Inc., IntelliCorp Records, Inc., and all other parties from liability that may result from information and opinions gathered about me. I release and indemnify Flying Colors of Success, Inc., IntelliCorp Records, Inc., and its representatives against any liability that arises out of such investigation. I understand that I will also receive a written disclosure of my rights under FCRA, 15 U.S.C. 1681 with the nature and sense of any investigative consumer report prepared on me upon my written request to IntelliCorp Records, Inc. but is made within a reasonable time after the date hereof. Nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Flying Colors of Success, Inc. and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise is binding upon this agency unless made in writing. I understand that Flying Colors of Success is an at-will employer. If any employment relationship is established, I understand that I have the right to terminate my employment at any time and that Flying Colors of Success, Inc. retains a similar right. If offered a job at Flying Colors of Success, Inc., I consent to taking a complete pre-employment physical examination and other examinations and/or medical test(s) as may be required in the future by this agency. I understand that my employment, or continued employment, may be contingent upon the results of these examination(s). MY SIGNATURE BELOW INDICATES THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ABOVE STATEMENTS. _ Signature of Applicant Date UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TO TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS
PROVISION IS GUILTY OF A MISDEMEANOR AND IS SUBJECT TO A FINE NOT TO EXCEED $100.00. _ Signature of Applicant Date