Ambience Community Services Application Step 1 of 4 25% Name First Middle Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberEmail What position are you applying for? How did you find out about this position? What shifts are you willing to work?Day Shift:Most PreferredWillingNot WillingOvernight Shift:Most PreferredWillingNot WillingPRN (as needed):Most PreferredWillingNot WillingAre you legally eligible for employment in the U.S.?YesNoAre you at least 18 years old?YesNoDid you graduate high school or receive your GED?YesNoDo you have a valid current Texas driver's license?YesNoIf required, can you meet the company's insurance requirements for driving positions?YesNoAre you willing to work overtime?YesNoAre you willing to work weekends?YesNoWhat is your desired salary? If hired, when can you start? Have you worked with individuals with IDD before and are you familiar with the position you are applying for?YesNoDo you have any relatives or friends who have worked for the company? If yes, who? Have you ever been charged with a misdemeanor or felony offense? If yes, please explain below.Please answer truthfully, a charge may not disqualify you, but a false answer will.Please briefly describe why you are interested in working with Ambience Community Services.What experience do you have with the special needs population?Do you have any special credentials, training or licenses (related to the position you are applying for)? If yes, list below.List any other special skills, experience or anything else that you feel we should know.Have you ever lost a license or received disciplinary actions? If yes, describe. EducationHigh SchoolName/Location of School Course of Study Diploma/Degree Received College/OtherName/Location of School Course of Study Diploma/Degree Received College/OtherName/Location of School Course of Study Diploma/Degree Received Previous EmploymentCompany PhoneLocation Supervisor Job Title Starting PayEnding PayJob Duties From MM slash DD slash YYYY To MM slash DD slash YYYY Reason for Leaving May we contact for a reference?YesNoCompany PhoneLocation Supervisor Job Title Starting PayEnding PayJob Duties From MM slash DD slash YYYY To MM slash DD slash YYYY Reason for Leaving May we contact for a reference?YesNoCompany PhoneLocation Supervisor Job Title Starting PayEnding PayJob Duties From MM slash DD slash YYYY To MM slash DD slash YYYY Reason for Leaving May we contact for a reference?YesNoCompany PhoneLocation Supervisor Job Title Starting PayEnding PayJob Duties From MM slash DD slash YYYY To MM slash DD slash YYYY Reason for Leaving May we contact for a reference?YesNoReferencesName Relationship Phone NumberName Relationship Phone NumberName Relationship Phone Number DPS Computerized Criminal History (CCH) VerificationI have been notified that a computerized criminal history (CCH) Verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB information I supply. Because the name based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization (as listed below) conducting the criminal history check is not allowed to discuss any information obtained using this method, therefore the agency may offer the opportunity to have a fingerprint search performed to clear any misidentification based on the name search, if the search provides a criminal report I know could not be mine. For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (automated fingerprint identification system). I have been made aware that in order to complete this process I must have the correct fingerprinting (FAST) form from this agency, make an online appointment, submit a full and complete set of my fingerprints, and pay a fee to the fingerprinting services company. Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.Authorization for Background ChecksRELEASE OF INFORMATION AUTHORIZED BY APPLICANT: By signing below, I authorize and request each former employer, person, firm or corporation given as a reference to answer all questions that may be asked, give all information that may be sought and confirm all information provided concerning me or my work habits, character, skills or my actions in any transaction. I therefore release all parties and persons connected with my request for information from liability for furnishing such information. CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK: Ambience Community Services is required to obtain criminal history record information on all applicants for employment. I am an applicant with Ambience Community Services and have been advised as a part of the application process, the employer conducts a criminal history background check. I do hereby consent to the employer use of any information provided the application process in performing the criminal history check. The employer has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment. LIST OF EXCLUDED INDIVIDUALS/ENTITIES, EMPLOYEE MISCONDUCT REGISTRY/ NURSE AID REGISTRY AND DEBARRED VENDORS: By signing below, I hereby authorize Ambience Community Services to verify my background with the List of Excluded Individuals/Entities, Employee Misconduct Registry, Nurse Aid Registry and Debarred Vendors. I understand this is a requirement of all applicants of Ambience Community Services. I understand that if I am listed on any of these registries I may be ineligible for employment with Ambience Community Services. I understand that if I am hired these registries will be checked at least annually and if I am listed at that time, I may be terminated. I also understand that if I become listed on any of these registries, I must notify Ambience Community Services immediately. MOTOR VEHICLE REPORT: By signing below, I hereby authorize Ambience CommunityServices to obtain a copy of my motor vehicle report. I understand that this will only be done if the position I am applying for requires driving and is only used to determine if I am an eligible driver for the company. I understand that my motor vehicle report will be checked on an annual basis and if I become an ineligible driver I may be terminated from employment. Applicant ConfirmationBy signing below, I certify that I have fully and accurately answered all questions and have given all information requested in this application for employment, and I understand that any wrong, incomplete or misleading information on the form may disqualify me for further consideration for employment or, if discovered after I am hired, may be grounds for my immediate dismissal. I understand that all information provided during the hiring process is subject to verification by Ambience Community Services. I give my consent and permit Ambience Community Services to investigate my background and qualifications using any means, sources, and outside investigators at its disposal. I understand that this application is not, and is not intended to be a contract of employment. Further, I understand that employment with Ambience Community Services is at will, which means that either I or Ambience Community Services can terminate the employment relationship at any time, with or without prior notice, and with or without cause. I understand and agree that if I become employed with Ambience Community Services, I will be required to abide by all rules and regulations of Ambience Community Services. I agree to undergo any type of drug and/or alcohol testing that the Company may require at any time. I understand that no offer for employment will be made until background checks are completed and if offered employment. Signature (full name) Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
