Tri-Development Center Online Application

Date*

Regarding employment, are you seeking:*

Full-time
Part-time

Choose all positions for which you are applying*

Residential Support Provider
LPN (ICF)-Full time
Program Plan Coordinator
Work Crew Supervisor
Skills Coach-Vaucluse Day Program
Residential Services Administrative Assistant/Rep Payee
Residential Services Manager-Trolleyline CTH II

Name*

First Last Initial

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

Home/Cell Phone*

Alternate Phone*

Name of Emergency Contact

Phone

Have you ever applied for employment with us?*

Yes
No

Have you ever been interviewed for a position with us?*

Yes
No

Have you ever been employed with us?*

Yes
No

Month & Year

Position

Who 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 us

Were you referred to this agency by a current employee? please list his/her name*

Name of the employee*

What is your expected salary range?*

Will you work overtime?*

Yes
No

Check all hours you are available to work*

Are you legally eligible for employment in the United States?*

Yes
No

Are you at least 18 years of age?*

Yes
No

Have you been a resident of South Carolina for the past 12 months?*

Yes
No

If not, in which state(s) did you live previously?*

Do you have a High School Diploma or GED? It is desired but not required.*

Yes
No

Do you have a valid driver’s license and a good driving record?*

Yes
No

Did you read a job description of the position for which you are applying?*

Yes
No

Do you meet the qualifications of the position for which you have applied?*

Yes
No

Can you perform the duties of the position, for which you have applied, with or without accommodations?*

Yes
No

Will you be available for 10 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)?*

Yes
No

Have you ever been involved in a substantiated case of abuse and/neglect?*

Yes
No

Please describe in detail

Tell us why you are interested in working with people with disabilities*

Education

High School

Name

City and State

Graduated

Yes
No

Diploma or GED

Business/Trade/Tech

Name

City and State

Graduated

Yes
No

Major

College

Name

City and State

Graduated

Yes
No

Major

Do you have LPN License?*

License Number*

Employment History

Start 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 Organization

Dates of Employment (Month and Year) From/To

City and State

Phone

Position held

Salary

Duties

Direct Supervisor

May we contact them?

Yes
No

Reason for not contacting previous employer

If you answered "No" to the question above, please brief description as to why below:

Additional Supervisor

Reason for leaving

Name under which you were employed - if different from now

Company or Organization

Dates of Employment (Month and Year) From/To

City and State

Phone

Position held

Salary

Duties

Direct Supervisor

May we contact them?

Yes
No

Reason for not contacting previous employer

If you answered "No" to the question above, please brief description as to why below:

Additional Supervisor

Reason for leaving

Name under which you were employed - if different from now

Company or Organization

Dates of Employment (Month and Year) From/To

City and State

Phone

Position held

Salary

Duties

Direct Supervisor

May we contact them?

Yes
No

Reason for not contacting previous employer

If you answered "No" to the question above, please brief description as to why below:

Additional Supervisor

Reason for leaving

Name under which you were employed - if different from now

Company or Organization

Dates of Employment (Month and Year) From/To

City and State

Phone

Position held

Salary

Duties

Direct Supervisor

May we contact them?

Yes
No

Reason for not contacting previous employer

If you answered "No" to the question above, please brief description as to why below:

Additional Supervisor

Reason for leaving

Name under which you were employed - if different from now

Additional 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 Managers

Name*

Title*

Name of Business*

City*

State*

Business Phone*

Contact Phone*

Name

Title

Name of Business

City

State

Business Phone

Contact Phone

Name

Title

Name of Business

City

State

Business Phone

Contact Phone

ALL EMPLOYEES OF TRI-DEVELOPMENT CENTER ARE EMPLOYED AT-WILL AND MAY QUIT OR BE TERMINATED AT ANY TIME AND FOR ANY REASON. NOTHING IN ANY OF 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 DURATION OF EMPLOYMENT, AND 4) THE DOCUMENT IS SIGNED BY THE EXECUTIVE DIRECTOR.

My signature below evidences my understanding that Tri-Development Center will 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 certify that all information given by me, to 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