Online Application Date* MM slash DD slash YYYY Choose all positions for which you are applying* Residential Support Provider LPN-PRN CTH II Weekend Relief Live-In-Residential Support Provider CTH I Residential Support Provider Groundskeeper Skills Coach Live-In Residence Caregiver Part-time Safety/Prevention Assistant Residential Services Manager-Dyches CTH II Employment Specialist Residential Services Manager-Hayne CTH II Residential Services Manager-Pinewood CTH II LPN-Full-Time Supported Employment Compliance Coordinator Name* First Last Initial Address* Street Address City State / Province / Region ZIP / Postal Code Email* Home/Cell Phone*Alternate Phone*Name of Emergency Contact PhoneHave 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 If referred to this agency by a current employee, please list his/her name What is your expected salary range?* Will you work overtime?* Yes No Check all hours you are available to work*DaysEveningsNightsWeekendsAre 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?* 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 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)?* 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 SchoolName City and State Graduated Yes No Diploma or GED Business/Trade/TechName City and State Graduated Yes No Major CollegeName City and State Graduated Yes No Major Employment 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 Organization Dates of Employment (Month and Year) From/To City and State PhonePosition held Salary Duties Direct Supervisor May we contact them? Yes No Reason for not contacting previous employerIf 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 PhonePosition held Salary Duties Direct Supervisor May we contact them? Yes No Reason for not contacting previous employerIf 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 PhonePosition held Salary Duties Direct Supervisor May we contact them? Yes No Reason for not contacting previous employerIf 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 PhonePosition held Salary Duties Direct Supervisor May we contact them? Yes No Reason for not contacting previous employerIf 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 ManagersName* Title* Name of Business* City* State* Business Phone*Contact Phone*Name Title Name of Business City State Business PhoneContact PhoneName Title Name of Business City State Business PhoneContact 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 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 the termination of employment were 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/EmployeeUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Δ
