Habilitation & Training Services, Inc.

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H.A.T.S. Employment Application

We are an equal opportunity employer and will not discriminate in the hiring process on the basis of sex, religion, race, color, creed, age, disability, military or veteran status, national origin or any other protected status. The workplace at HATS is smoke free in compliance with the Tennessee Nonsmoker Protection Act.

PERSONAL INFORMATION
*Last Name
*First Name
*Social Security Number:
*Present Address:
*City:
*State:
*Zip:
Previous Address (if less than 3 yrs.):
City:
State:
Zip:
*Are you 18 years or older?
YESNO
Home Phone:
Cell Phone:


DESIRED EMPLOYMENT
Position:
Date You Can Start:
Salary Needed:
*Are you employed now?
YESNO
If so, may we inquire of your present employer?
YESNO
*Ever applied to or worked with this agency before?
YESNO
If so, where and when did you work for HATS?


EDUCATION
School Level Name & Location of School Number of Years Attended Did you graduate? Subjects Studied
Grammar School YES
NO
High School YES
NO
College YES
NO
Trade/ Business/ Correspondence YES
NO


GENERAL
Special skills and training:


FORMER EMPLOYERS

Provide past work history containing a continuous description of activities over the past five years, starting with the most recent employer.

Name of Present or Last Employer 1:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Name of Supervisor:
*May we contact your supevisor?
YESNO
Phone:
Description of work:
Reason for leaving:


Name of Present or Last Employer 2:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Name of Supervisor:
*May we contact your supevisor?
YESNO
Phone:
Description of work:
Reason for leaving:


Name of Present or Last Employer 3:
Address:
City:
State:
Zip:
Starting Date:
Leaving Date:
Job Title:
Name of Supervisor:
*May we contact your supevisor?
YESNO
Phone:
Description of work:
Reason for leaving:


REFERENCES

Below, give names of three persons you are not related to, whom you have known at least five years.

Name Address or Daytime Phone Number Relationship Years Acquainted


MILITARY SERVICE RECORD
Branch of Service Discharge Date & Rank


Have you ever been convicted of any of the crimes listed below? YESNO


I, the undersigned applicant, certify and affirm that, to the best of my knowledge and belief; I have or have not had a case of abuse, neglect, mistreatment, or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation I further release and authorize HATS, Inc. and the Tennessee Division of Mental Retardation Services to have full and complete access to any and all current or prior personnel or investigative records, from any party, person, business or agency, as pertains to any investigation against me of abuse, neglect, or mistreatment and to consider this information as may be deemed appropriate.

Signature: APPLICANT TO PROVIDE IF CALLED FOR INTERVIEW         Date:


AUTHORIZATION

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application will be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the agency has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. I understand in order to be considered for employment, the application must be completed in full.

Date:         Signature: APPLICANT TO PROVIDE IF CALLED FOR INTERVIEW


Release Authorization

Applicant Please Read Complete the Following:

  1. In connection with my application for employment, I understand that a consumer report or an investigative report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, we may be requesting information from public and private sources about my: workers' compensation injuries, driving record, court records. education, credentials, credit, and references. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
  2. Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) andlor any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a Consumer Reporting Agency. If so, I will be notified and given the name and address of the agency or the source that provided the information.
  3. I acknowledge that a telephone facsimile (FAX) or photographic copy shall be valid as the original. This release is valid for most federal, state and county agencies.
  4. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by HATS, Inc. or its agent to furnish the information described in Section 1.
  5. I hereby authorize release of information from the Department of Transportation regulated drug and alcohol testing records by my previous employer to HATS, Inc. This release is in accordance with DOT regulation 49CFR Part 40, Section 40.25 I understand that information to be released by my previous employer, is limited to the following DOT regulated items, alcohol tests with a result of 004 or higher, verified positive drug tests, refusals to be tested, and violations of DOT agency drug and alcohol testing regulations, information obtained from previous employers of a drug and alcohol rule violation, and any documentation of completion of the returnĚto~dutyprocess following a rule violation. This DOT information may also include my past driving citations, such as accidents and speeding.
  6. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports.

This consumer report will be used for employment purposes and may be subject to the Fair Credit Reporting Act. I may receive a free copy of this report. Before any adverse action is taken based on this report I will receive copy of the report and notice of my rights under the FCRA.

Full Legal Name:
*Last Name

*First Name

*Middle Name
Maiden Name & Alias Names:
Current Home Address:
Social Security Number: Date of Birth:
The following states require sex and race to obtain information: AL, AR, FL, FA, lA, IL, IN, MI, OR, SC, TX, WI
Sex:Male Female
Race:Asian Black HispanicWhite Other
Driver's license Number: State Issued:
Name as it appears on license:
Signature: APPLICANT TO PROVIDE IF CALLED FOR INTERVIEW         Date:


STATEMENT FOR RELEASE OF INFORMATION
Date:
Name of Agency & Region: Habilitation and Training Services, Inc. - Middle
Full Name of Employee:
*Last Name

*First Name

*Middle Name
Previously Used Names (nickname, maiden, etc.):
Social Security Number:
Driver's license Number:
State Issued:
I, certify and affirm that to the best of my knowledge and belief
I Have OR
I Have Not
had or received a finding of a substantiated case of abuse, neglect, mistreatment, or exploitation against me. In order to verify this affirmation, I further release and authorize HATS, Inc. and the Department of Developmental Disabilities to have full and complete access to any and all personnel or investigative records as it pertains to any substantiated allegations against me of abuse, neglect, mistreatment, or exploitation.
Signature of Employee: APPLICANT TO PROVIDE IF CALLED FOR INTERVIEW
Date:
Signature of Witness: PROVIDED IF APPLICANT IS CALLED FOR INTERVIEW
Date:


To print and mail-in a paper application, CLICK HERE.
(in PDF document format)

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