Community Living Concepts

APPLICATION FOR EMPLOYMENT

Community Living Concepts, Inc. (CLC) and Community Opportunities, Inc. (COI) are Equal Opportunity Employers. Persons leaving employment with CLC, or COI may be eligible to continue their insurance coverage under the Consolidated Omnibus Budget Reconciliation Act commonly known as COBRA.

I. PERSONAL DATA

Name:	Date:
Address:	City:	State:	ZIP:
Phone:	Positions Applied for:
Email:
Do you have a valid Texas Drivers License?
Are you 21 years of age or older?
Are you legally eligible for employment in the United States?
Have you ever been convicted or received deferred adjudication for any felony offense or do you currently have any pending charges which would disqualify you from employment with people with developmental disabilities?
If the answer to the previous question was yes please explain:

II. Educational History

Please check the highest level attended:
Elem. School	High School/GED	College	Graduate School
Degree Obtained:

III. Military Service

Have you ever served in the U.S. Armed Forces?
If yes, what branch?
Type discharge obtained:

IV. Work History

List in reverse order, beginning with your current or most recent employment, your last three employers and information about the work performed.

1.	Employer's Name:	Address
City:		State:	ZIP:
Supervisor's Name:		Job Title:	Phone:

Duties and responsibilities:

From:
To:
Reason for leaving:
Ending salary:

2.	Employer's Name:	Address
City:		State:	ZIP:
Supervisor's Name:		Job Title:	Phone:

Duties and responsibilities:

From:
To:
Reason for leaving:
Ending salary:

3.	Employer's Name:	Address
City:		State:	ZIP:
Supervisor's Name:		Job Title:	Phone:

Duties and responsibilities:

From:
To:
Reason for leaving:
Ending salary:

Continue your work history but provide only the following information:

	Employer Name	City	Job Title	From	To
4.
5.
6.
7.
8.
9.
10.
Explain how you feel your previous experience can help you in your work with people with developmental disabilities:

Do you have relatives/friends presently or previously employed with CLC, Inc.or COI?
If yes, who and what is their relationship to you?

V. Personal References

Please list three individuals who know you to serve as references.

1.	Name:	Address:
	City:	State:	ZIP:
	Phone:	Relationship to you

2.	Name:	Address:
	City:	State:	ZIP:
	Phone:	Relationship to you

3.	Name:	Address:
	City:	State:	ZIP:
	Phone:	Relationship to you

Please read and initial each of the following statements:
By entering your initials after the following statements you are agreeing to each of these statements

1. The information I have provided is true and complete to the best of my knowledge. I understand that if employed, any false statement will be considered cause for possible dismissal from employment.

2. I affirm that I do not have a conviction of, pending charges of or an employment history of child abuse, neglect or mistreatment of or abuse and neglect of a person receiving services.

3. I affirm that I have not been convicted or received deferred adjudication or have any pending charges of an offense under the Health and Safety Code, section 250.005 subject to the criminal penalties of the Texas Penal Code section 37.10 which would bar my employment in an IVF/MR.

4. I hereby authorize Community Living Concepts, Inc. to request information from previous employers regarding past employment and performance.

If you are unable to initial the affirmation in numbers 2 or 3 above, please explain:

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