Application for Employment

Family Centered Services of Alaska, Inc. / 1825 Marika Road, Fairbanks, Alaska 99709/ (907) 474-0890/FAX: 907-451-8945

____________________________________            ______________________             _______                                ______________

Last Name                                                      First Name                              M. I.                Date

Current Address  ______________________________________________________________________________

                                    Street                                       City                              State                 Zip      

Telephone Number (_____)_____________________            Social Security Number ________- ________- _________

Are you authorized to work in the U.S. on an unrestricted basis?              Yes                  No

Please list all relatives employed with Family Centered Services of Alaska: ________________________________

How did you learn of this opening:  ____________________    Have you worked here before?        Yes         No

Shift Preferred:  Part Time ___  Full Time __  Relief/On – call __  Any__  Day___  Evening___  Night____

Do you have a valid Driver’s License       Yes    No      Is your vehicle insured?    Yes     No  (May transport clients)

Have you ever been terminated (fired) from another job?   Yes   No    If yes, please explain:  __________________

____________________________________________________________________________________________

Have you ever been convicted of a felony?                      Yes_____                   No ______

(Answering “yes” will not necessarily disqualify an applicant for employment.)     If yes, describe conditions: _______________

____________________________________________________________________________________________

In addition to your work history (reverse side) what other experiences, skills or qualifications would especially qualify you for work with our company?

WORK HISTORY

References Required: One (1) Personal (PR) and two (2) Professional (PF)

APPLICANT’S CERTIFICATION AND AGREEMENT

I certify that the facts sets set forth in this Application for Employment is true and complete to the best of my knowledge.  I understand that if I am employed, false statements may result in my dismissal.  I understand that FCSA is an “At Will” employer and may terminate my employment with or without cause and with or without notice.  I authorize FCSA to make an investigation of any of the facts set forth in this application.  I give my permission for FCSA to contact the work references and personal references and authorize those references to provide any information requested: 

____________________________________________________________            ________/________/________

                                    Signature                                                                                          Date  

_______________________________________________________________

NAME

Notice to all applicants

All applicants seeking employment with Family Centered Services of Alaska will be subject to a background investigation.  The results of this investigation will be considered, both prior to and after employment, in determining continued employment with FCSA.  If any adverse information is found during the background investigation, you will be dismissed from employment with Family Centered Services of Alaska.

Family Centered Services of Alaska complies with all state and federal laws prohibiting discrimination in employment.  FCSA exercises equal employment opportunity and affirmative action policies as required by state and federal law.  Family Centered Services of Alaska is an “At-Will” employer.  “At-Will” is defined as:

1. An FCSA employee may resign their employment at any time with or without notice and for any reason.

      2.    FCSA may terminate an employee at any time with or without notice and with or without cause.