Community Rehabilitation Center Inc. Employment Application

Community Rehabilitation Center Inc.

623 Beachwood Street

Jacksonville, FL 32206

AT-WILL EMPLOYMENT APPLICATION

THIS APPLICATION IS NOT AN EMPLOYMENT CONTRACT, but merely is intended to provide information necessary to evaluate suitability for employment. It is the policy of the company to provide equal employment to all qualified persons without discrimination on the basis of sex, race, color, religion, age, marital status, national origin, citizenship, disability, veteran status, or any other status protected under state of federal law. It is also the policy of Community Rehabilitation Center (CRC) to have the option of conducting pre-employment screening before a job offer is made. If a job offers made, employment may be contingent upon the successful completion of a medical examination, which may include drug test or other physical evaluation. We are an equal opportunity employer and drug-free workplace. This application will remain active for 180 days.

Personal Information * Required Fields

* How were you referred:

* Full Name:

* Address:

* City:

* State:

* Zip:

* Your E-mail:

* Phone:

* Mobile/Other:

* 18 Years Or Older:

Yes No

* If NO, please explain:

* Requirement:

* Date You Can Start:

* Salary Expectations:

* Worked here before:

Yes No

* If YES, When:

* Citizen - United States?

Yes No

* If NO, legally allowed?

Yes No

* Type of employment:

Full-Time
Part-Time
Temporary
Seasonal

* Ever been convicted ?

Yes No

* If YES, give dates/details:

Answering "yes" to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

EDUCATION

High School Attended

City

County

State

Did you earn a Diploma?

YES

Undergraduate College Attended

City

State

Area of Study

Degree/Certificate/Diploma

YES

Graduate School Attended

City

State

Area of Study

Degree/Certificate/Diploma

YES

Trade, Business or Other School

City

State

Area of Study

Degree/Certificate/Diploma

YES

List any work experience relative to the position you’re applying, to include job related skills, certifications, etc.

Previous Employment (begin with most recent position):

Dates of Employment:	From: To:
Positions(s) Held:
Firm / Company:
Address of Employer:
Phone Number:
Supervisor:
Title of Supervisor:
Your Responsibilities:
Starting Salary & Title:
Ending Salary and Title:
Reason for Leaving:
May we contact this employer for reference ?	Yes No

Previous Employment
Dates of Employment:	From: To:
Positions(s) Held:
Firm / Company:
Address of Employer:
Phone Number:
Supervisor:
Title of Supervisor:
Your Responsibilities:
Starting Salary & Title:
Ending Salary and Title:
Reason for Leaving:
May we contact this employer for reference ?	Yes No

Previous Employment
Dates of Employment:	From: To:
Positions(s) Held:
Firm / Company:
Address of Employer:
Phone Number:
Supervisor:
Title of Supervisor:
Your Responsibilities:
Starting Salary & Title:
Ending Salary and Title:
Reason for Leaving:
May we contact this employer for reference ?	Yes No

APPLICANT'S STATEMENT

APPLICANT'S CERTIFICATION AGREEMENT

1. I certify that the fact and information set forth in this application are true and complete of the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on the application or on any required documents will be cause for denial of employment of immediate termination of employment, regardless of when of how discovered.

2. I authorize the investigation of all statements contained in the application and release from all liability any persons or employers supplying such information, and I also release CRC from all liability that might result form making the investigation.

3. If I am offered and accept a position, I agree to conform to all existing and future Company rules and regulations and I understanding that CRC reserves the right to change my work department, wages, hours and working conditions as deemed necessary. I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY MAY END THE EMPLOYMENT RELATIONSHIP AT ANY TIME AND FOR ANY OR NO REASON.

4. I understand that any employment offer is contingent upon my providing, within (3) working days of employment, valid proof of identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986.

5. I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.

I have read and agree to

CRC's APPLICANT'S CERTIFICATION AGREEMENT