Company Address:

14703 Holbrook's Rd , Huntersville NC,28078

Fax Number :

704-275-5038

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Business Phone

Cell/Pager

Services or Job(s) Applied for:

What hours are you available?

How did you become aware of SZL Mothers Assistance Inc?

Website

Word of Mouth

Customer Choice (who)?

SZL Mothers Assistance Inc Direct Support Professional, family or Other (who)?

Other:

Are you eligible to work in the United States?

Yes

Do you have documentation to prove citizenship, permanent residency (“green card”), or current work visa?

Yes

Please note: documentation will be required prior to being offered a position.

Have you ever filled out an application with this agency?

Yes

Are you related to a DSP receiving services from of SZL Mother's Assistance?

Yes

If “YES,” list name and relationship:

EDUCATION

High School

Name & Location

Dates Attended

Degree/Major

Year Graduated

College/University

Name & Location

Dates Attended

Degree/Major

Year Graduated

Graduate or Professional

Name & Location

Dates Attended

Degree/Major

Year Graduated

Other Technical/Vocational Internships, etc.

Name & Location

Dates Attended

Degree/Major

Year Graduated

*For some positions you may be asked to provide a transcript. List fields for which you are licensed, registered, or certified. Give dates and sources of issuance.

HISTORY

Current or Last Position:

Address & Telephone #:

Position Title:

Supervisor:

Dates of Position:

Responsibilities:

Previous Position:

Address & Telephone #:

Title:

Supervisor:

Dates of Position:

Responsibilities:

Have you ever been convicted of an offense against the law other than a minor traffic violation? (A conviction does not mean you cannot be hired. The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying. If yes, explain fully.)

Yes

If YES, explain fully.

Have you ever been disciplined or discharged for?

Yes

If Yes, explain

Absenteeism?

Yes

If Yes, explain

Alleged child/client abuse, neglect, exploitation, or involvement?

Yes

If Yes, explain

Tardiness?

Yes

If Yes, explain

Serious infraction of company policy?

Yes

If Yes, explain

Failure to notify company of absence?

Yes

If Yes, explain

Workplace violence?

Yes

If Yes, explain

Character Reference

(Please indicate two professional and two personals. No relatives are to be included.)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day phone number

Evening Phone Number

Relationship to you

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Day phone number

Evening Phone Number

Relationship to you

• Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of or, if employed, termination of employment. • The company will make a thorough investigation of my entire work and personal history and may verify all data given in my application, related papers, or oral interviews. I authorize such investigation and the giving and receiving of such information. I understand that falsification of data so given, or any other derogatory information discovered as a result of this investigation may prevent my being hired or, if hired, my subject me to immediate dismissal. • My position or employment is “at will” and may be terminated by this company at any time without liability for wages or salary except such as may have been earned at the date of such termination. If requested by management at any time, I agree to submit to search of my person or of any personal space that may be assigned to me, with cause, and I hereby waive all claims for damages on account of such examination, at company expense, at any time to determine if I am physically fit for the position I am to perform, and I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of the position for which I am being considered prior to beginning services or employment or in the future during my service provision or employment with the company. • My position may not begin until I have attended the new provider orientation and attain certification for completion of all training required of privilege. • This is an application for service provision in which a contract will be provided or in the case of employment, no employment contract is being offered. • If I am employed, such employment is for an indefinite period of time and the company can change wages, benefits, and conditions at any time. • If I am accepting a contract position, the terms of the contract will be reviewed as necessary. • I must meet all eligibility requirements for work in the United States and have documentation to prove citizenship, permanent residency (“green card”), or current work visa status.

I understand and agree that:

• Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal of or, if employed, termination of employment.

• The company will make a thorough investigation of my entire work and personal history and may verify all data given in my application, related papers, or oral interviews. I authorize such investigation and the giving and receiving of such information. I understand that falsification of data so given, or any other derogatory information discovered as a result of this investigation may prevent my being hired or, if hired, my subject me to immediate dismissal.

• My position or employment is “at will” and may be terminated by this company at any time without liability for wages or salary except such as may have been earned at the date of such termination. If requested by management at any time, I agree to submit to search of my person or of any personal space that may be assigned to me, with cause, and I hereby waive all claims for damages on account of such examination, at company expense, at any time to determine if I am physically fit for the position I am to perform, and I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of the position for which I am being considered prior to beginning services or employment or in the future during my service provision or employment with the company.

• My position may not begin until I have attended the new provider orientation and attain certification for completion of all training required of privilege.

• This is an application for service provision in which a contract will be provided or in the case of employment, no employment contract is being offered.

• If I am employed, such employment is for an indefinite period of time and the company can change wages, benefits, and conditions at any time.

• If I am accepting a contract position, the terms of the contract will be reviewed as necessary.

• I must meet all eligibility requirements for work in the United States and have documentation to prove citizenship, permanent residency (“green card”), or current work visa status.

Certification of Application

I hereby certify that all statements made in this application and my attachments to it are true. I understand that any misstatement, misrepresentation, or omission of fact may be the cause for my application not to be considered; or if I have been employed, may be cause for my immediate dismissal. I authorize the President/CEO of SZL Mothers Assistance Inc, or his designee to verify information contained in this application and attachments. I further authorize anyone having such information to release it. I further understand that any offer of employment is conditional upon passing a physical examination, drug test, criminal background check, and driving record check. I have received and agreed to abide by the above stated policies.

Signature

Date

Prior to service provision we must have all the following documents in your file in addition to the necessary training. If you do not have these documents, please begin obtaining them now. *When you turn in this application you must at minimum give copies of your Social Security Card and Driver’s License* for background checks.

• Social Security Card (MUST be the card issued by Social Security) – If you have lost your card, please reapply at Social Security and attach verification provided by Social Security that a new card has been requested. Once the card is received, it MUST be provided to SZL Mothers Assistance Inc.

• Driver’s License (Current and valid). If transportation is a position function, or state issued picture identification card, if transportation is not required and you do not have a Driver’s License.

• Auto Insurance Declarations Page showing amounts of Vehicle Insurance coverage in the event that transportation is to be a job function.

• CPR and First Aid Certification (CPR/First Aid cards or certificate)

• Medication and Administration Certification

• High School diploma or equivalency – Verification of completion of at least high school or GED (copy of diploma, signed statement from school official, high school transcript, college diploma/transcripts, teaching certification, etc.). services cannot begin without receipt of this information. Note: If you have a college degree or for QP’s, a copy of the college transcript is required.

• Alternatives to Restrictive Interventions training — EBPI, CPI or other approved training.

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