Application for Employment

CHESCO Inc. does not discriminate in hiring or employment on the basis of race, color, creed, religion, sex, marital status, national origin, age, mental or physical disability, sexual orientation, genetic predisposition, carrier status or veteran status. No question on this application is intended to secure information to be used for such discrimination.

Date *

Last Name *

First Name *

Middle Initial *

Phone *

Email *

Street Address *

City *

State *

Zip *

List the addresses you have lived at over the past ten years. *

Are you under 18 years of age? *

Are you legally eligible for employment in the United States? *

If you are less than 18 years of age, can you provide required proof of your eligibility to work? *please select

Have you filled an application with us before? *

If yes on previous question, please give date

Have you ever been employed with us before? *

If yes, please give date

Job duties: *

Reason for leaving: *

Have you ever been employed in the human service field in the Monadnock Region or any other area? *

If you have, please give date *

Job duties required

Reason for leaving the position *

Are you currently employed? *

If yes, may we contact your present employer? *

On what date are you available to work? *

Are you available to work: *please select

Are any relatives or acquaintances employed with us? *

If yes, please list

Where did you learn about CHESCO, Inc. and/or position vacancy? *

Criminal Information

Have you ever been convicted of a felony or a misdemeanor? *

Note: FAILURE TO DISCLOSE A CONVICTION FOR ANY CRIME (FELONY OR MISDEMEANOR) WILL BE CONSIDERED AN INTENTIONAL OMISSION. Convictions will not necessarily disqualify an applicant for employment. Each one is considered in relation to the position applied for.

If yes, please indicate: Nature of the Offence

Date of conviction and penalty *

Name and location of the court *

Have you ever had a complaint filed against you that was founded for abuse, neglect or exploitation at ANY Agency or Region? *

If yes, please explain in detail stating location, date, charges, and penalty of each offense:

Do you have any criminal charges pending against you? *

If yes, please indicate the nature of the charges:

Driving Information

Driver License # *

State *

Expiration Date *

Is the above a valid driver’s license? *

Have you been driving for at least three years? *

Have you ever been licensed to drive in ANY OTHER STATE? *

If so, which states?

Have you ever been convicted of DUI, Reckless Driving or other serious violations? *

If yes, explain in detail stating location, date, charges, and penalty of each offence:

Have you had any traffic convictions in the past ten years? *

If yes, please explain in detail stating location, date, charges, and penalty of each offense:

Has your driver license ever been suspended or revoked? *

If yes, please state location, date and type of suspension, cancellation or denial:

Have you had an accident in the past ten years? *

If yes, please explain

Education

Name of high school *

Number of high school years completed *

Dimploma: *

GED: *

Name of college

Number of college years completed

College major

Degree

Other schooling

Employment Experience

Employer #1

Dates employed at job #1 Start / Finish

Address for Employer #1

Phone - Employer #1

Job title or position at job #1

Hourly rates or salary at job #1 Starting / Final

Supervisor at job #1

Reason for leaving job #1

Employer #2

Dates employed at job #2 Start / Finish

Address for Employer #2

Phone - Employer #2

Job title or position at job #2

Hourly rates or salary at job #2 Starting / Final

Supervisor at job #2

Reason for leaving job #2

Employer #3

Dates employed at job #3 Start / Finish

Address for Employer #3

Phone - Employer #3

Job title or position at job #3

Hourly rates or salary at job #3 Starting / Final

Supervisor at job #3

Reason for leaving job #3

Employer #4

Dates employed at job #4 Start / Finish

Address for Employer #4

Phone - Employer #4

Job title or position at job #4

Hourly rates or salary at job #4 Starting / Final

Supervisor at job #4

Reason for leaving job #4

If there have been any gaps in your employment during the past five years, please provide details in the space provided:

References

Give below the names of three persons not related to you whom you have known for at least one year in a business relationship.

Name of Reference #1

Address for Reference #1

Business Name of Reference #1

Phone for Reference #1

Name of Reference #2

Address for Reference #2

Business Name of Reference #2

Phone for Reference #2

Name of Reference #3

Address for Reference #3

Business Name of Reference #3

Phone for Reference #3

Additional Information

Are you capable of performing with or without reasonable accommodation the essential functions of the job or occupation for which you have applied?

Note to the applicants: DO NOT ANWSER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Release of Information:

PLEASE READ BEFORE SIGNING:

I hereby certify that all statements made by me on this application and accompanying resume (if any) are true and correct to the best of my knowledge and belief, and that I have withheld nothing that would, if disclosed, materially affect the application unfavorably. I hereby grant CHESCO, Inc. permission to verify such statements and information including all past work history in the service system. In addition, I give permission to verify that I have not had any founded allegations of abuse or neglect against me. I understand that any misrepresentation or omission of information made by me during the recruitment process may be considered as sufficient cause for rejection of this application or, if employed, termination regardless of when the correct information is obtained.

I hereby authorize the release of my employment dates, evaluations of working performance, opinions and any other relevant information to CHESCO, Inc. or its agents. If applicable, this is to authorize the registrar/Placement Office to release my educational transcript and information in my placement records to CHESCO, Inc. I hereby release all parties with such relevant information and CHESCO, Inc. from any liability on account of such disclosures.

I acknowledge that this application is not intended to be a contract of employment. I understand and agree that, if hired, my employment is for no definite period of time and may, regardless of the date of payment of my wages or salary, be terminated at any time.

Date *

Your Name *

By checking this box, you agree that listing your name above serves as your legal signature. *

Contact us today with your question or for more information.

"I like the whole company because it's not a nursing home setting. Chesco is a whole environment filled with family and friends. Chesco is designed to make individuals comfortable and to live there life's as normal as possible. Also, we can make our own discussions in where we live, what we eat, where we shop, and what we do daily."

~ Jeannie Fergusion