Employee Application

Southern Arizona Family Services Inc.

For Office Use Only
Date of Last Interview / Interviewer Name
Hired: Yes □ No □ Indefinite □ / Hire Date
Notes/ Comments:
Application
This application must be filled out in its entirety
Date: / Employment □ Full Time
□ Part Time □ On Call / Preferred # of Hours:
Name: / Email Address:
Address: / City: / State: / Zip:
Date of Birth: / Social Security Number:
Home Phone: / Secondary Phone Number:
Emergency Contact Information
Name:
Relationship:
Phone #: ( ) - ______- ______/ How did you hear about us?
Newspaper □ Television □ Internet Ad □
Recommended by: ______
Other: ______
Certificates/Qualifications:
CPR □ First Aid □ Article 9 □ Direct Care Worker □ Prevention and Support □ Class 1 Finger Print Clearance □ Languages:(English □ Spanish □ Other ______)
Other Certifications/Qualification:
Hours of Availability (please specify times and days below)
Monday / From / To
Tuesday / From / To
Wednesday / From / To
Thursday / From / To
Friday / From / To
Saturday / From / To
Sunday / From / To
Personal Data
Have you ever been convicted or a crime or been imprisoned? A conviction will not necessarily bar you from employment: If yes, please explain:
Names of friends or relatives who are employed by SAFS:
Have you ever worked at SAFS before? ____Yes ___No
Employment History
(begin with most recent employer—attach additional sheets if necessary)
Employer / From / To
Address / City / State / Zip
Phone No. / Beginning Wages / Ending Wages
Manager’s Name / Your job Title
Reason for Leaving:
Okay to Call? ___Yes ___No
I give Southern Arizona Family Services Inc. permission to contact the above employer/reference for verification.
Applicant Signature:______Date:______
Employer / From / To
Address / City / State / Zip
Phone No. / Beginning Wages / Ending Wages
Manager’s Name / Your job Title
Reason for Leaving:
Okay to Call? ___Yes ___No
I give Southern Arizona Family Services Inc. permission to contact the above employer/reference for verification.
Applicant Signature:______Date:______
Employer / From / To
Address / City / State / Zip
Phone No. / Beginning Wages / Ending Wages
Manager’s Name / Your job Title
Reason for Leaving:
Okay to Call? ___Yes ___No
I give Southern Arizona Family Services Inc. permission to contact the above employer/reference for verification.
Applicant Signature:______Date:______
School History
High School / Location / Did you graduate? ___Yes ___No / Degree: ___Diploma
___GED
College/School / Location / Did you graduate? ___Yes ___No
Course of Study / Major / Degree
College/School / Location / Did you graduate? ___Yes ___No
Course of Study / Major / Degree
References
(Must include at least1 professionalreference, other 2 may be personal but known at least 1 year)
Name / Phone Number
Address / City / State / Zip
Relationship / Years known:
Name / Phone Number
Address / City / State / Zip
Relationship / Years known:
Name / Phone Number
Address / City / State / Zip
Relationship / Years known:

By signing this application, I certify: That this application is complete and accurate to the best of my knowledge and that I have not made any attempt to conceal information and that falsification could be cause for dismissal. Further, Southern Arizona Family Services Inc, or its agents may request employment information from my previous employers and persons or corporations who provide information related to my previous employment and will be released from any liability or damage. Also, I agree if required to undergo a medical examination by a company designated physician and understand that medical approval must be obtained before employment can be effective. I have noted that is Southern Arizona Family Services Inc and Equal Opportunity Employer and as applicants receive lawful consideration for employment without regard to Race, Religion, Color, Sex, Age, National Origin, Disability, or Veteran status. I realize that if I am hired, Southern Arizona Family Services Inc, reserves the right to terminate my employment whenever the need arises.

Signature / Date

Privacy Release

I,______, an applicant for the insurance with the Social Service Contractor’s Indemnity Pool (SSCIP), herby consent to a review of my driving record with the Motor Vehicle Division for the purpose of determining my eligibility for coverage and for performing an evaluation of the premium due for that coverage. I understand and agree that driving record through the Motor Vehicle Division or by other means for those purposes.

To the extent that this review of my driving record is an invasion of my privacy rights, I waive those rights for the purpose of evaluation of my insurance application.

______

Dated Signature

______

Printed Name

______

Employer

Transportation

Cross Streets: ______

For transportation

______I have my own vehicle

______I get rides from friends or family

______I use the bus

______Other: ______

I would be willing to:

______transport clients in my vehicle (must provide proof of insurance, DL, and registration)

I would be willing to work in the following regions:

______North

______Northeast

______Northwest

______West

______East

______Southeast

______Southwest

______South

Records Request from

Motor Vehicles Division

Upon acceptance of employment from Southern Arizona Family Services (hereafter referred to as SAFS) I the employee understand that I will need to obtain a copy of my Motor Vehicle Records (MVR). This information needs to be turned in prior to working with clients. I understand that there is a fee of $3.00 to be paid by myself utilizing a credit card if I do not have a credit card I can go to the MVD offices for more payment options. I can get my MVR online at or at any MVD office. Whether online or at the MVD office I will be able to obtain my records the same day that I request them.

Thank you,

SAFS

Supplemental Information

Thank you for applying with Southern Arizona Family Services. We would like to take this opportunity to inform applicants that you must obtain the following classes. CPR, First Aid, both of these classes is offered through SAFS for a $20.00 fee for each class. You can take these classes outside of SAFS; however you must obtain them before starting work. If you choose classes from SAFS see Ron Berry for schedules and paying the class fee.

______Signature

______Date

All new hires are required to obtain a T.B. test; we use Concentra on Broadway, across from the El Con Mall. Or you can go to your Dr., or the Pima County Health Dept. This must be completed prior to starting work, and will need to be renewed annually.

______Signature

______Date