Employment Application Employment Application form Step 1 of 8 12% Date POSITION DESIRED*Available Start Date* Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HOW DID YOU LEARN ABOUT THIS JOB OPENING?*INDEEDZIPRECRUITERCURRENT EMPLOYEEFRIENDHOME TELEPHONEMOBILE PHONE*EMAIL* DAYS/HOURS AVAILABLE TO WORK:MONDAY*TUESDAY*WEDNESDAY*THURSDAY*FRIDAY*SATURDAY*SUNDAY* EMPLOYMENT HISTORY Starting with your current position and going backward, please provide the following information about all employment you have held since completing your full-time education. 1EMPLOYED: FROM Mo. Yr.:TO Mo. Yr.:NAME AND LOCATIONPOSITIONCOMPENSATION: Start:END:REASON FOR MAKING CHANGE:(*If involuntary, provide an explanation below)(*If involuntary, provide an explanation below)2EMPLOYED: FROM Mo. Yr.:TO Mo. Yr.:NAME AND LOCATIONPOSITIONCOMPENSATION: Start:END:REASON FOR MAKING CHANGE:(*If involuntary, provide an explanation below)(*If involuntary, provide an explanation below)3EMPLOYED: FROM Mo. Yr.:TO Mo. Yr.:NAME AND LOCATIONPOSITIONCOMPENSATION: Start:END:REASON FOR MAKING CHANGE:(*If involuntary, provide an explanation below)(*If involuntary, provide an explanation below)4EMPLOYED: FROM Mo. Yr.:TO Mo. Yr.:NAME AND LOCATIONPOSITIONCOMPENSATION: Start:END:REASON FOR MAKING CHANGE:(*If involuntary, provide an explanation below)(*If involuntary, provide an explanation below)5EMPLOYED: FROM Mo. Yr.:TO Mo. Yr.:NAME AND LOCATIONPOSITIONCOMPENSATION: Start:END:REASON FOR MAKING CHANGE:(*If involuntary, provide an explanation below)6EMPLOYED: FROM Mo. Yr.:TO Mo. Yr.:NAME AND LOCATIONPOSITIONCOMPENSATION: Start:END:REASON FOR MAKING CHANGE:(*If involuntary, provide an explanation below) EDUCATION HISTORY Starting with your highest education level and working backward, please provide the following information about all formal education you have received. (Seminars, workshops, and employer-sponsored training should be included in the section "Additional Training.") HIGH SCHOOLNAME:LOCATIONYEARS COMPLETED1234TRADE OR OTHERNAME:LOCATIONYEARS COMPLETED1234MAJORDEGREE RECEIVEDCOLLEGENAME:LOCATIONYEARS COMPLETED1234MAJORDEGREE RECEIVEDGRADUATENAME:LOCATIONYEARS COMPLETED1234MAJORDEGREE RECEIVED OTHER QUESTIONSAre you at least 18 years of age?*YESNO2. Are you available to work (check all that apply):*Full-TimePart-TimeTemporary4. The position you are applying for may require you to work overtime and/or weekends, are you able to fulfill this requirement?*YESNO5. The position you are applying will require your schedule to remain flexible, are you able to fulfill this requirement?*YESNO6. Are you bilingual, or do you speak another language?*YESNOIf yes, please list below:7. Did anyone refer you to CSA?*YESNOIf yes, who?8. Are you willing and able to travel?*YESNO9. Can you, after hiring, provide proof of your identity and authorization to work in the United States?*YESNO10. Have you ever been convicted of a crime, *including either a felony or misdemeanor? A "conviction" includes a plea, verdict or finding of guilt regardless of whether sentence was imposed by the court.YESNOIf yes, state location, date and description. (A conviction will not necessarily disqualify you from employment.) *You must not list (1) convictions related to marijuana more than two years ago, (2) convictions which have been judicially sealed, expunged or statutorily eradicated, including convictions during which you were a minor (3) misdemeanor convictions for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed, (4) any information concerning a referral to, and participation in, any pretrial or post trial diversion program. ADDITIONAL TRAININGPlease describe any additional training or professional development you have pursued, starting with the most recent and working backward.* ADDITIONAL INFORMATIONIf your responses to the above questions do not account for all of the years since high school, please describe your activities during the times unaccounted for.Do you have any licenses or certifications which would be relevant to the position for which you are applying? Please describe.*Is there any other information about you which we should know to evaluate your candidacy for the position for which you are applying? (Exclude information which might indicate race, sex, color, age, national origin or any other protected classification.) Please describe.*So that we may verify the information which you have provided in this application, have you ever been known by any other name which might identify you on employment, education, military or other records? Please list the names and indicate dates on which they applied.* REFERENCES Please provide the names of at least three persons not related to you whom you have known for at least one year. Name:Relationship:Address:Phone:2 Name:Relationship:Address:Phone:3 Name:Relationship:Address:Phone:4 Name:Relationship:Address:Phone: Applicant’s Authorization I hereby authorize the above listed references to furnish Creative Solutions for Hope with any information they may have concerning me which is on record or otherwise, and do hereby release the above listed references including Creative Solutions for Hope, from any and all liability whatsoever that might otherwise be incurred in furnishing such information. * I authorize CSH to contact the above listed references. IMPORTANT There are several important aspects of employment with the Company which you should be aware of before completing this Application for Employment I expressly agree and understand that my employment, having no specified term, is based upon mutual consent and may be terminated at will, with or without cause or notice, by either party (CSA or me). I also understand that this at-will aspect of my employment, which includes CSA right to demote, transfer or otherwise discipline me with or without cause or notice, may not be changed, waived or modified, except in an individualized written agreement signed by both me and the owner of the Company. The Company maintains a drug-free workplace in accordance with its Drug and Alcohol Policy and Screening Program. As a condition of employment with the Company, and after an offer of employment has been extended to you, you must successfully complete a physical examination and a drug and alcohol screening test. In addition, the Company reserves the right to administer a physical examination or a drug or alcohol screening test to any and all employees at any time during their employment, for cause as determined by the Company. The Company may seek to verify the information you have provided in this Application for Employment. By signing below, you acknowledge your understanding that the Company, its parent, subsidiaries, affiliates and any of its (their) employees or agents (collectively referred to as the Company) will require you to execute a stand-alone disclosure form authorizing and releasing the Company to contact the persons or organizations you have listed and to discuss your background with them. I understand that, if I become employed by the Company, I will be subject to and expected to comply with all the rules, regulations and procedures of the Company. You further acknowledge and represent that you are not subject to any non-competition agreement or other agreement that would prevent or impede in any way your employment with CSA. If you believe you may be, or may have been, a party to an agreement not to compete against any past employer, you must disclose the existence, or potential existence, of such agreement to CSA Human Resources department for further assessment. I understand that the hiring process is not complete and I will not become an employee of the Company until I have reviewed, completed and executed various employment documents including, but not limited to, this Application, the Company Employee Handbook and Employee Handbook Acknowledgment Form, Arbitration Agreement, Consent and Disclosure Regarding Procurement of Consumer Credit Report and for Investigative Consumer Report and an At-Will Employment and Confidentiality Agreement. I declare under penalty of perjury that all of the information which I have provided on this Application for Employment or any resume or other documentation provided by me in connection with this Application for Employment is true and complete, and I understand that if any of the information is determined to be false, even if that determination is made years later, it will result in my immediate discharge from employment with the Company. My signature below acknowledges the information that I have provided is true and accurate, I further acknowledge all the statements on this form.