Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Position
*
Are you legally eligible to work in the United States?
How did you learn about our agency?
Have you previously been employed by or contracted with A Helping Hand Inc.?
Have you applied at A Helping Hand Inc. in the last 12 months?
If yes, list the date and address where you applied:
List the names of any immediate family members who are currently an employee or Board member of A Helping Hand Inc. or any of its affiliates or branches:
U.S. MILITARY SERVICE
PREVIOUS EMPLOYER OR CONTRACTED AGENCY
First Name
Last Name
Company & business Type
Phone
(###)
###
####
Description of Job
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
PREVIOUS EMPLOYER OR CONTRACTED AGENCY
First Name
Last Name
Company & business Type
Phone
(###)
###
####
Description of Job
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Graduated?
Degree Received
College, City and Major:
Graduated?
Degree Received
Additional Education? Share below
Conviction Record: Have you been convicted of a felony in the past ten years? If Yes, please explain
LICENSED COUNSELOR or Intern Number:
State
Expiration Date
MM
DD
YYYY
Licensed Credential
Medicaid Provider #
HAVE WE MISSED SOMETHING IMPORTANT?
Please use the space below to note down any special activity, awards, or other information that may help us to understand your skills and abilities that will be helpful on this job:
Personal References (Not Employers or Relatives)
Have you ever been found guilty or entered a plea of guilty or nolo contendere (no contest), regardless of the adjudication of crime other than traffic violations? If Yes, please explain
Have you ever been substantiated for child abuse, abandonment, and/or neglect or disabled adult abuse and/or neglect?If yes, please explain
PLEASE READ CAREFULLY & Sign Below
“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed by or contracted with, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give you information concerning my previous employment or contracted experience and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.
I understand and agree that, if hired or contracted with, it is for no definite period and may, regardless of the date of payment of my compensation, be terminated with a 10-day notice unless your contract is dissolved due to cause and then it will be without prior notice.”
By signing this form, I am swearing that I have no criminal, history which would adversely affect my capacity to work with
children and adults.
First Name
Last Name
Date Signed
MM
DD
YYYY
