Online Application Date* Date Format: MM slash DD slash YYYY Choose all positions for which you are applying* Residential Support Provider LPN-PRN Live-In Caregiver Smith CTH I CTH II Weekend Relief Live-In-Residential Support Provider Case Manager with the Aiken County Board of Disabilities LPN-Full-time Behavioral Support Specialist Work Crew Supervisor Residential Services Manager-Jewel Street CTH II Program Plan Coordinator Name* First Last Initial Address* Street Address City State / Province / Region ZIP / Postal Code Email* Home/Cell Phone*Alternate Phone*Name of Emergency ContactPhoneHave you ever applied for employment with us?*YesNoHave you ever been interviewed for a position with us?*YesNoHave you ever been employed with us?*YesNoMonth & YearPositionWho was your Supervisor?*Why did you leave?*Falsification of these questions could result in your application not being considered. State names of relatives or friends working for usIf referred to this agency by a current employee, please list his/her nameWhat is your expected salary range?*Will you work overtime?*YesNoCheck all hours you are available to work*DaysEveningsNightsWeekendsAre you legally eligible for employment in the United States?*YesNoAre you at least 18 years of age?*YesNoHave you been a resident of South Carolina for the past 12 months?*YesNoIf not, in which state(s) did you live previously?*Do you have a High School Diploma or GED?*YesNoDo you have a valid driver’s license and a good driving record?*YesNoDid you read a job description of the position for which you are applying?*YesNoDo you meet the qualifications of the position for which you have applied?*YesNoCan you perform the duties of the position, for which you have applied, with or without accommodations?*YesNoWill you be available for 8 consecutive working days of paid training during the first of the month and 2 more consecutive working days of paid training near the end of the month (Mon - Fri from 8:00am to 4:00pm)?*YesNoHave you ever been involved in a substantiated case of abuse and/neglect?*YesNoPlease describe in detailHave you ever been convicted, plead guilty or no contest to any offense other than a minor traffic violation? (You must include the following if any apply to you: driving under suspension, failure to pay a fine, driving under the influence/driving while intoxicated, failure to stop for blue lights, writing fraudulent checks and unlawful use of a telephone.) A Yes answer will not necessarily disqualify you from employment.*YesNoPlease describe in detailTell us why you are interested in working with people with disabilities*Education High SchoolNameCity and StateGraduatedYesNoDiploma or GED Business/Trade/TechNameCity and StateGraduatedYesNoMajor CollegeNameCity and StateGraduatedYesNoMajorEmployment HistoryStart with your present or most recent Employer. Please give accurate, complete full-time and part-time employment record. We may contact the employers listed below unless you indicate otherwise. If submitting a Resume, we ask that you still fill out the entire application .Please Print Information. Please List All Phone Numbers. Company or OrganizationDates of Employment (Month and Year) From/ToCity and StatePhonePosition heldSalaryDutiesDirect SupervisorMay we contact them?YesNoReason for not contacting previous employerIf you answered "No" to the question above, please brief description as to why below: Additional SupervisorReason for leavingName under which you were employed - if different from nowCompany or OrganizationDates of Employment (Month and Year) From/ToCity and StatePhonePosition heldSalaryDutiesDirect SupervisorMay we contact them?YesNoReason for not contacting previous employerIf you answered "No" to the question above, please brief description as to why below: Additional SupervisorReason for leavingName under which you were employed - if different from nowCompany or OrganizationDates of Employment (Month and Year) From/ToCity and StatePhonePosition heldSalaryDutiesDirect SupervisorMay we contact them?YesNoReason for not contacting previous employerIf you answered "No" to the question above, please brief description as to why below: Additional SupervisorReason for leavingName under which you were employed - if different from nowCompany or OrganizationDates of Employment (Month and Year) From/ToCity and StatePhonePosition heldSalaryDutiesDirect SupervisorMay we contact them?YesNoReason for not contacting previous employerIf you answered "No" to the question above, please brief description as to why below: Additional SupervisorReason for leavingName under which you were employed - if different from nowAdditional Professional References Please read: If you have only had a few jobs, you may also list names of other people you have actually worked for such as: college professors, volunteer coordinators, ministers, child care, lawn care, etc. References must be from responsible individuals who can comment on your employment abilities, character, and reliability but, cannot be anyone related to you. Information about additional Supervisors or ManagersName*Title*Name of Business*City*State*Business Phone*Contact Phone*NameTitleName of BusinessCityStateBusiness PhoneContact PhoneNameTitleName of BusinessCityStateBusiness PhoneContact Phone ALL EMPLOYEES OF AIKEN COUNTY BOARD OF DISABILITIES/TRI-DEVELOPMENT CENTER ARE EMPLOYED AT-WILL AND MAY QUIT OR BE TERMINATED AT ANY TIME AND FOR ANY REASON. NOTHING IN ANY OF AIKEN COUNTY BOARD OF DISABILITIES/TRI-DEVELOPMENT CENTER’S RULES, POLICIES, MANUALS, PROCEDURES OR OTHER DOCUMENTS RELATING TO EMPLOYMENT CREATES ANY EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT. NO PAST PRACTICES OR PROCEDURES, WHETHER ORAL OR WRITTEN, FORM ANY EXPRESS OR IMPLIED AGREEMENT TO CONTINUE SUCH PRACTICES OR PROCEDURES. NO PROMISES OR ASSURANCES, WHETHER WRITTEN OR ORAL, WHICH ARE CONTRARY TO OR INCONSISTENT WITH THE LIMITATIONS SET FORTH IN THIS PARAGRAPH CREATE ANY CONTRACT OF EMPLOYMENT UNLESS: 1) THE TERMS ARE PUT IN WRITING, 2) THE DOCUMENT IS LABELED “CONTRACT”, 3) THE DOCUMENT STATES THE DURUATION OF EMPLOYMENT, AND 4) THE DOCUMENT IS SIGNED BY THE EXECUTIVE DIRECTOR. My signature below evidences my understanding that Aiken County Board of Disabilities/Tri-Development Center may conduct a criminal records investigation, a sexual offender check, and an abuse/neglect investigation as well as an employment history investigation, background check and motor vehicle record investigation. I further understand that information obtained during the investigation(s) may be used as a basis for the denial of appointment or reappointment, as well as termination of employment where appointed to a position pending completion of my records check investigation. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I also understand that refusal to sign this release will result in termination of the employment process. I certify that all information given by me, in my application for employment with the ACBD/TDC, is true in all respects and, I authorize the use of any information in the application to enable the agency to verify my statements. I authorize past employers, all references and any other persons to answer all questions asked by the agency concerning my ability, character, reputation and previous employment record. I release all such persons from any liability or damages for furnishing such information. The information provided on this Application for Employment is true, correct, and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal.Signature of Applicant/Employee