APPLICATION FOR EMPLOYMENT
401 N. Buffalo Dr., Suite 202
Las Vegas, NV 89145
Notice: We are an equal opportunity employer and do not discriminate on the basis of an applicants or employees race, color, region, sex, national origin, citizenship, age, physical or mental disability or any other characteristics. All applicants are subject to random drug testing.
Date:______
Name: Last First Middle
Present AddressCity StateZip Code
Permanent Address (if different than above)City StateZip Code
Social Security NumberTelephone Number
Federal Law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver’s license, birth certificate, green card, etc.)
Position applied for: ______
Yes / No / If Yes, please describe.Is there any information we would need about your name or use of another name for us to be able to check your employment record?
Do you have any relatives who are presently (or formerly) employed by Journeys Community Services, Inc.?
Have you ever been convicted of a DUI?
Have you ever been arrested?
Have you ever been convicted of a misdemeanor or felony?
**** Please refer to next page to review disqualifying convictions ****
How were you referred to Journeys Community Services, Inc.? ______
Disqualifying Criminal Convictions
(References: NRS 449.174 and Medicaid Services Manual 2100)
If you learn from the Department of Public Safety or any other source that an individual has been convicted of a crime listed below you may not employ, or retain employment, of that individual if working in any capacity that would have direct contact with individuals served by the Regional Centers. Most offense listed prevents you from employing that individual. However, please notice that there is a difference in some offenses between misdemeanor and felony, whereas a felony conviction is an unlimited employment prohibition and a misdemeanor conviction is prohibited from employment in the immediately following 7 years.
Unlimited Convictions
You may not employ any individual who has ever been convicted of any of the following:
- Murder, voluntary manslaughter or mayhem.
- Assault with intent to kill or to commit sexual assault or mayhem.
- Sexual assault, statutory sexual seduction, incest, lewdness, indecent exposure or any other sexually related crime that is punished as a felony.
- A crime involving domestic violence that is punished as a felony. (See NRS 33.018 for definition).
- Abuse or neglect of a child or contributory delinquency.
- Abuse, neglect exploitation or isolation of any older persons or vulnerable persons, including, a violation of any provision of NRS 200.50955 or 200.5099, inclusive, or a law of any other jurisdiction that prohibits the same or similar conduct.
- A violation of any provision of NRS 422.450 to 422.590, inclusive, relating to Nevada’s State Plan for Medicaid.
- Any other felony involving the use or threatened use of force or violence against the victim or the use of a firearm or other deadly weapon.
Seven-year Convictions
You may not employ any individual who has been convicted within the past seven years of any of the following:
- Any violation of any federal or state law regulating the possession, distribution or use of any controlled substance or any dangerous drug as defined in Chapter 454 or NRS, within the immediately preceding 7 years.
- Misdemeanor Prostitution, solicitation, lewdness or indecent exposure, or any other sexually related crime that is punished as a misdemeanor, within the immediately preceding 7 years.
- A crime involving assault or battery, domestic or otherwise, that is punished as a misdemeanor, within the immediately preceding 7 years. (See NRS 33.018 for definition which includes assault, battery, and compelling a person by force or threat of force to perform an act from which the other person has the right to refrain…).
- A violation of any provision of law relating to the State Plan for Medicaid or a law of any other jurisdiction that prohibits the same or similar conduct, within the immediately preceding 7 years.
- A criminal offense under the laws governing Medicaid or Medicare, within the immediately preceding 7 years.
- Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property, within the immediately preceding 7 years.
- An attempt or conspiracy to commit any of the offenses listed in this paragraph, within the immediately preceding 7 years.
Applies to Applicant
Does not apply to Applicant
______
Signature of Applicant
DRIVING STATUS: PLEASE CHOOSE ONE, SIGN AND DATE
DRIVER:
By signing below, I understand that if I am offered employment with Journeys Community Services, Inc., I must maintain a reliable vehicle, a valid NV driver license, registration and insurance. If any of the items previously listed are no longer valid, have been revoked or suspended, I will notify Journeys Community Services immediately. Journeys Community Services, Inc. will not be held liable for any accidents that may occur if I am not properly licensed or insured.
If I am currently a valid driver in another state, I agree that I will follow the State of Nevada’s law by transferring my driver license, registration and insurance within 30 days of being employed by Journeys Community Services, Inc. If my driver license, registration and insurance are not transferred in a timely manner, I understand that I may be terminated and/or have my hours reduced.
If at any time my driving status changes while employed with Journeys Community Services, Inc., I understand that it could lead to a reduction of hours and/or termination.
______
Signature:Date:
NON DRIVING STATUS:
By signing below, I understand that if I am offered employment with Journeys Community Services, Inc. this is a NON-DRIVING position. At no time will I be authorized to drive as a representative of Journeys Community Services, Inc.
By agreeing to be a non-driver, I understand that this limits my ability to obtain SLA client hours and/or positions within the ISLA homes.
______
Signature:Date:
EDUCATIONAL HISTORY:
School Name/City, StateYears Completed Diploma/Degree
EMPLOYMENT RECORD:
1.______
Company Name (Current/Most Recent)Position Held
______
Company Address Employment Dates: Start to End
______
Manager /SupervisorWage/Salary
______
Telephone Number
2.______
Company Name (Current/Most Recent)Position Held
______
Company Address Employment Dates: Start to End
______
Manager /SupervisorWage/Salary
______
Telephone Number
3.______
Company Name (Current/Most Recent)Position Held
______
Company Address Employment Dates: Start to End
______
Manager /SupervisorWage/Salary
______
Telephone Number
Note: Use a separate sheet to list additional employers if necessary. We will contact all employers listed on this application unless you specifically exclude the employer as noted below. Please list any employer(s) you do not wish for Journeys to contact. Briefly explain the reason for the exclusion.
Employer’s Name Reason
REFERENCES: Please do not list relatives or former employers.
1.______
Name Years Known
______
Address Telephone
2.______
Name Years Known
______
Address Telephone
3.______
Name Years Known
______
Address Telephone
WORK AVAILABILITY:
1. If your application receives favorable consideration when will you be available for employment?
2. Do you have any objections to working overtime? ( ) Yes ( ) No
3. Can you work overtime without prior notice? ( ) Yes ( ) No
4. Can you travel if required? ( ) Yes ( ) No
SALARY/HOURLY RATE REQUIREMENTS:
If your application receives favorable consideration, what salary/hourly rate would you require?
$______PER______
______
SignatureDate
EMERGENCY CONTACT:
______
NamePhone Number
Journeys Community Services, Inc. is a certified and/or approved contract provider of the
Nevada Developmental Services (DS) Regional Center. The Nevada DS Regional Centers require that all employee applicants complete the following questions:
1)Have you ever worked with any agency which contracts with the State of Nevada Developmental Services Regional Centers (Desert, Rural or SierraRegionalCenter)? Yes No
2)Have you ever worked for an agency, either within or outside, of the State of Nevada that serves a vulnerable population e.g. children, seniors or developmentally disabled? Yes No
3)Have you ever been the accused (placed on re-assignment/administrative leave) in an abuse, neglect or exploitation complaint and/or investigation? Yes No
If so, were the accusations confirmed or substantiated?YesNo
If yes, what was the outcome? (Check all that apply.)
TerminationSuspensionRetrainingOther
Describe:
I declare that the information provided to the above questions is true and complete.
Print NameSignature
Date
AUTHORIZATION FOR PRIOR EMPLOYER TO RELEASE INFORMATION
I, ______, hereby authorize my prior employer, ______, to
PRINTYOUR NAME
release any and all information relating to my employment with them to Journeys Community Services, Inc.
I further release and hold harmless both ______and Journeys Community Services, Inc.
from any and all liability that may potentially result from the release and/or use of such information. I
understand that any information released by my prior employer will be held in strictest confidence, that it
will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so
involved will have the right to see the information.
______
Signature of Perspective Employee Date
AUTHORIZATION FOR PRIOR EMPLOYER TO RELEASE INFORMATION
I, ______, hereby authorize my prior employer, ______, to
PRINTYOUR NAME
release any and all information relating to my employment with them to Journeys Community Services, Inc.
I further release and hold harmless both ______and Journeys Community Services, Inc.
from any and all liability that may potentially result from the release and/or use of such information. I
understand that any information released by my prior employer will be held in strictest confidence, that it
will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so
involved will have the right to see the information.
______
Signature of Perspective Employee Date
AUTHORIZATION FOR PRIOR EMPLOYER TO RELEASE INFORMATION
I, ______, hereby authorize my prior employer, ______, to
PRINTYOUR NAME
release any and all information relating to my employment with them to Journeys Community Services, Inc.
I further release and hold harmless both ______and Journeys Community Services, Inc.
from any and all liability that may potentially result from the release and/or use of such information. I
understand that any information released by my prior employer will be held in strictest confidence, that it
will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so
involved will have the right to see the information.
______
Signature of Perspective Employee Date
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Revision Date: 01/08/2016