Orange Grove Center, Chattanooga, Tennessee: Employment Application

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Employment Application

Orange Grove Center Employment Application

This application will remain active for 3 months from the date you apply. Please complete the entire application. Incomplete applications will not be processed.
Date:
Last Name:	First: MI:
SSN:
E-Mail:
Home Phone:	- Message Phone: -
Address:	City:
County:	State: Zip:

AVAILABILITY
Have you ever been employed by Orange Grove Center? Yes No
If Yes, What name? Dates:
Positions applied for:
1. 2. 3.
Category preferred: Full-time Part-time Temporary
Minimum Pay you are seeking:
What hours are you available?
Weekdays Weekends Evenings Nights
How did you hear about us?
Employee:
Advertisement Employment Agency Walk-in Job fair

JOB-RELATED SKILLS
Yes No	Are You legally eligible for employment in the United States?
Yes No	Do you have a valid driver's license?
	Name as on license:
	Class: Endorse: State of Issue:
	Expiration date:
Yes No	Have you had any moving traffic violations? Please list:
Yes No
Yes No	Have you ever been bonded?
	When?
	For what position?
Yes No	Has bond ever been refused? If yes, please explain:
Yes No
Yes No	Have you ever been licensed or practiced professionally under a different name?
Yes No	Have you ever had a nursing license, or other professional license, in any jurisdiction limited, suspended, revoked or relinquished?
Yes No	Have you ever been sanctioned for misconduct by a professional or trade organization or agency?
Yes No	Have you ever had any malpractice claims, suits, settlements or arbitration proceedings involving your professional practice?

PROFESSIONAL CERTIFICATION List registration, certification or license you hold
Type:
Expiration date:
Number:
State:
EDUCATION HISTORY Check the highest grade completed
5 \| 6 \| 7 \| 8 \| 9 \| 10 \| 11 High School Diploma \| GED College: \| 1 \| 2 \| 3 \| College Degree Graduate School: 1 \| 2 \| 3 \| 4
High School:	Name:
	City:
College:	Name:
	City:
Major:
Minor:
Degrees completed:
Orange Grove Center is an EQUAL OPPORTUNITY EMPLOYER. Federal and state laws, and our own company policy, prohibit discrimination in employment on the basis of age, sex, race, national origin, religion, or disability. Persons denied employment based on above conditions may file a complaint with our firm and/or with state or federal authorities.
EMPLOYMENT HISTORY
List last 3 jobs. YOU ARE REQUIRED TO FILL OUT THIS SECTION, EVEN IF YOU SENT A RESUME. We will make every effort to contact previous employers; the correct telephone numbers of past employers are critical.

1. Current or Most Recent Employer
Company:
Telephone Number:		-
Address:
City:		State: Zip:
Job Title:
Supervisor's Name:
Dates Employed:		From: To:
Your Duties and Responsibilities
Salary		per
Reason for leaving

2. Past Employer
Company:
Telephone Number:		-
Address:
City:		State: Zip:
Job Title:
Supervisor's Name:
Dates Employed:		From: To:
Your Duties and Responsibilities
Salary		per
Reason for leaving

3. Past Employer
Company:
Telephone Number:		-
Address:
City:		State: Zip:
Job Title:
Supervisor's Name:
Dates Employed:		From: To:
Your Duties and Responsibilities
Salary		per
Reason for leaving

If more than three (3) Previous Employers, List:
1. Past Employer
Company:
Telephone Number:		-
		City: State:
Job Title:
Dates Employed:		From: To:
Salary		per
Reason for leaving

2. Past Employer
Company:
Telephone Number:		-
		City: State:
Job Title:
Dates Employed:		From: To:
Salary		per
Reason for leaving

3. Past Employer
Company:
Telephone Number:		-
		City: State:
Job Title:
Dates Employed:		From: To:
Salary		per
Reason for leaving

Have you ever served in any branch of the U.S. military service? Yes No
If yes, what branch?
Vietnam Era veteran (180 days active service from 8/5/64 to 5/7/75) Disabled Veteran
References: This section MUST be completed. Include only individuals familiar with your work ability. Do not include relatives or past employers.

1. Name:
Address:
City:	State Zip
Phone:	-
Years Known:	Relationship:

2. Name:
Address:
City:	State Zip
Phone:	-
Years Known:	Relationship:

3. Name:
Address:
City:	State Zip
Phone:	-
Years Known:	Relationship:

Security
In Chronological order, list ALL cities and states where you have lived in the past 10 years.
1.
2.
3.
4.
List any names or social security numbers you have used:
1.
2.
3.
4.
5.

Yes No	Have you ever been convicted of or served time for a felony? List below Please do not disclose a criminal conviction, if the conviction has been expunged, sealed or eradicated.
Yes No	Have you ever been charged with child abuse?
Yes No	Have you ever been convicted of any violations for which you paid a fine of more than $100.00? List below.
Yes No	Has a child in your custody or control ever been declared dependent or neglected? If yes to any of the above, please list below.
Yes No	Are you currently engaging in the illegal use, sale or distribution of Drugs? If yes, explain:

(In accordance with Orange Grove Center, Inc. policy a conviction will not necessarily disqualify you from the job for which you are applying. A conviction will be judged on its merits with respect to time, circumstances and seriousness.
List incidents

1. Incident:
Date:
City:				State:
Charge:
2. Incident:
Date:
City:				State:
Charge:
3. Incident:
Date:
City:				State:
Charge:

IN CASE OF EMERGENCY, PLEASE NOTIFY:
Name:
Relation:
Phone:	-
Address:
City:	State: Zip:
CERTIFICATION AND RELEASE
I hereby certify that I have read this application and the answers given by me to the questions and statements are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize Orange Grove Center, Inc. and/or its agents, including customer-reporting bureaus, to verify any of this information. I authorize all former employers, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said employers, schools companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.
Name
Date
After submitting this information, you will be asked to complete another shorter form.

This page was last updated on Thu Jul 17, 2008.

Day Services Calendar 2008-2009

Employment Application

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Orange Grove Center • 615 Derby Street • Chattanooga, Tennessee 37404 • Phone: 423.629.1451