APPLICATION FOR EMPLOYMENT

FAMILYCONNECTIONS IS AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER COMMITTED TO EXCELLENCE.

EMPLOYMENT OFFERS ARE MADE ON THE BASIS OF QUALIFICATIONS AND WITHOUT REGARD TO RACE, SEX, RELIGION,
NATIONAL OR ETHNIC ORIGIN, DISABILITY, AGE, VETERAN STATUS, OR SEXUAL ORIENTATION OR OTHER PROTECTED
CLASSES UNDER STATE OR FEDERAL LAW.

PLEASE TYPE OR PRINT:

COMPLETE THE ENTIRE APPLICATION. YOU MAY ATTACH A RESUME, BUT YOU MUST

STILL COMPLETE ALL QUESTIONS; OR YOUR APPLICATION WILL BE DEEMED INCOMPLETE AND MAY NOT BE CONSIDERED.

NAME (LAST, FIRST, MIDDLE):

OTHER NAMES UNDER WHICH YOU HAVE ATTENDED

SCHOOL OR BEEN EMPLOYED:

STREET ADDRESS:
W HAT IS THE BEST WAY TO
CONTACT YOU?

CITY, STATE & ZIP:

HOME PHONE:

ARE YOU ELIGIBLE TO WORK IN THE U.S.?

W ORK PHONE:

YES
NO
IF YES, UPON EMPLOYMENT YOU
WILL BE REQUIRED TO PROVIDE
DOCUMENTATION ESTABLISHING
YOUR IDENTITY AND ELIGIBILITY
TO WORK IN THE UNITED STATES.
YES
NO
YES
NO

ARE YOU 18 YEARS OF AGE OR OLDER?

ARE YOU PRESENTLY EMPLOYED?

HAVE YOU EVER BEEN EMPLOYED BY

FAMILYCONNECTIONS?

YES

NO

DO YOU HAVE ANY RELATIVES OR FRIENDS

WHO WORK FOR THE COMPANY?

YES

NO

FULL-TIME

CELL/OTHER PHONE:
SALARY DESIRED:

AVAILABLE START DATE:

IF YES, MAY WE CONTACT YOUR
EMPLOYER?
YES
NO
IF YES, DATES OF EMPLOYMENT & REASON
FOR LEAVING:
IF YES, THEIR NAME & THEIR
RELATIONSHIP TO YOU?

IF REQUIRED FOR POSITION, DO YOU HAVE

YES
NO
A VALID DRIVERS LICENSE?
IF REQUIRED FOR POSITION, DO YOU HAVE
YES
NO
A VALID CDL LICENSE?
HOW DID YOU LEARN ABOUT THIS EMPLOYMENT OPPORTUNITY?
POSITION DESIRED:

E-MAIL ADDRESS:

IF YES, STATE OF ISSUANCE, LICENSE #,

AND EXPIRATION DATE:
IF YES, STATE OF ISSUANCE, LICENSE #,
AND EXPIRATION DATE:

PART-TIME

IF PART-TIME, SPECIFY DAYS AND HOURS:

IF YOU HAVE ANY QUESTION AS TO WHAT FUNCTIONS OF THE JOB ARE APPLICABLE TO THE POSITION FOR WHICH YOU ARE
APPLYING, PLEASE ASK THE INTERVIEWER BEFORE YOU ANSWER THIS QUESTION
EDUCATION:
NAME OF SCHOOL

CITY/STATE

DID YOU
GRADUATE?

HIGH SCHOOL:

YES

NO

GED:

YES

NO

OTHER SCHOOL:

YES

NO

COLLEGE:

YES

NO

COLLEGE:

YES

NO

COURSE OF STUDY/
M AJOR

DEGREE
RECEIVED

COLLEGE:

YES

NO

CLINICAL OR PROFESSIONAL LICENSE TYPE:

LICENSE# AND EXPIRATION:
LIST ACADEMIC HONORS, EXTRACURRICULAR ACTIVITIES, OFFICES HELD, ETC. IN HIGH SCHOOL OR COLLEGE:

OTHER CREDENTIALS/ LICENSES/ PROFESSIONAL AFFILIATIONS, ETC., WHICH ARE RELEVANT TO THE JOB(S) FOR WHICH YOU
ARE APPLYING.

IN THE LAST SEVEN (7) YEARS, HAVE YOU BEEN CONVICTED OF OR HAVE YOU PLEADED GUILTY TO ANY
CRIME?* (PLEASE EXCLUDE MINOR TRAFFIC OFFENSES AND CONVICTIONS WHICH HAVE BEEN SEALED, IMPOUNDED, ERASED,
EXPUNGED, ANNULLED OR NULLED)
HAVE YOU EVER BEEN CONVICTED OF A SEX-RELATED OR CHILD ABUSE RELATED CRIME?
NOTE: SUBJECT TO N.J.S.A. 60:6D-63, A CONVICTION WILL NOT NECESSARY BE A BAR TO EMPLOYMENT. THE NATURE OF THE OFFENSE,
DATE OF THE OFFENSE AND SURROUNDING CIRCUMSTANCES AND THE RELEVANCE OF THE OFFENSE TO THE POSITION(S) APPLIED FORM MAY,
HOWEVER, BE CONSIDERED.

SKILLS:

PLEASE LIST TECHNICAL SKILLS, CLERICAL SKILLS, TRADE SKILLS, ETC., RELEVANT TO THIS POSITION. INCLUDE
RELEVANT COMPUTER SYSTEMS AND SOFTWARE PACKAGES OF WHICH YOU HAVE A WORKING KNOWLEDGE, AND NOTE YOUR
LEVEL OF PROFICIENCY (BASIC, INTERMEDIATE, EXPERT)

WORK EXPERIENCE: PLEASE DETAIL YOUR WORK HISTORY FOR THE PAST TEN YEARS. BEGIN WITH YOUR CURRENT OR
MOST RECENT EMPLOYER. IF YOU HELD MULTIPLE POSITIONS WITH THE SAME ORGANIZATION, DETAIL EACH POSITION
SEPARATELY. ATTACH ADDITIONAL SHEETS IF NECESSARY. OMISSION OF PRIOR EMPLOYMENT MAY BE CONSIDERED
FALSIFICATION OF INFORMATION. PLEASE EXPLAIN ANY GAPS IN EMPLOYMENT. INCLUDE FULL-TIME MILITARY OR VOLUNTEER
COMMITMENTS. PLEASE DO NOT COMPLETE THIS INFORMATION WITH THE NOTATION SEE RESUME.
DATES EMPLOYED

FULL TIME

PART-TIME

TITLE:

(MOST RECENT EMPLOYER)

FROM:

TO

IF PART-TIME, # HRS./WKS.:

STARTING SALARY:
FINAL SALARY:

IS THIS YOUR CURRENT EMPLOYER?

YES
NO
SUPERVISORS NAME, TITLE AND PHONE:

MAY WE CONTACT YOUR SUPERVISOR?

YES
NO

ORGANIZATION NAME AND ADDRESS:

REASON FOR LEAVING:

PRIMARY DUTIES:

DATES EMPLOYED
FROM:

TO

IS THIS YOUR CURRENT EMPLOYER?

YES
NO

FULL TIME

PART-TIME

IF PART-TIME, # HRS./WKS.:

TITLE:
STARTING SALARY:
FINAL SALARY:

SUPERVISORS NAME, TITLE AND

PHONE #:

OTHER REFERENCE NAME, TITLE AND

PHONE #:

ORGANIZATION NAME AND ADDRESS:

MAY WE CONTACT YOUR SUPERVISOR?

YES
NO

REASON FOR LEAVING:

PRIMARY DUTIES:

DATES EMPLOYED
FROM:

TO

FULL TIME

PART-TIME

IF PART-TIME, # HRS./WKS.:

IS THIS YOUR CURRENT EMPLOYER?

YES
NO

TITLE:
STARTING SALARY:
FINAL SALARY:

SUPERVISORS NAME, TITLE AND PHONE #:

MAY WE CONTACT YOUR SUPERVISOR?

YES
NO

ORGANIZATION NAME AND ADDRESS:

REASON FOR LEAVING:

PRIMARY DUTIES:

DATES EMPLOYED
FROM:

TO

FULL TIME

PART-TIME

IF PART-TIME, # HRS./WKS.:

IS THIS YOUR CURRENT EMPLOYER?

YES
NO

TITLE:
STARTING SALARY:
FINAL SALARY:

SUPERVISORS NAME, TITLE AND PHONE #:

MAY WE CONTACT YOUR SUPERVISOR?

YES
NO

ORGANIZATION NAME AND ADDRESS:

REASON FOR LEAVING:

PRIMARY DUTIES:

REFERENCES: NAME 3 PERSONS, NOT RELATED TO YOU, ONE OF WHICH WAS AN IMMEDIATE SUPERVISOR, WHOM YOU
HAVE KNOWN FOR AT LEAST ONE YEAR AND WHO CAN SERVE AS A PROFESSIONAL REFERENCE FOR YOU.
NAME

PHONE NUMBER

RELATIONSHIP TO REFERENCE

APPLICANTS CERTIFICATION AND AGREEMENT:

I CERTIFY THAT THE INFORMATION PROVIDED BY ME IN THIS APPLICATION IS ACCURATE AND COMPLETE TO THE BEST OF
MY KNOWLEDGE AND BELIEF, AND AGREE THAT SUCH INFORMATION MAY BE INVESTIGATED BY FAMILY CONNECTIONS AT
ANY TIME. I UNDERSTAND THAT ANY FALSE STATEMENTS OR MISREPRESENTATION OF THE FACTS CALLED FOR IN THIS
APPLICATION OR IN THE HIRING PROCESS WILL BE CAUSE FOR REJECTION OF MY APPLICATION OR DISMISSAL FROM
EMPLOYMENT AT ANY TIME.

I AUTHORIZE AND REQUEST ALL OF MY PRESENT AND FORMER EMPLOYERS AND THOSE WHOM I HAVE LISTED AS
REFERENCES TO FURNISH FAMILY CONNECTIONS, EITHER ORALLY OR IN WRITING, WITH ANY AND ALL INFORMATION THEY

MAY HAVE CONCERNING MY EMPLOYMENT, INCLUDING ALL ATTENDANCE RECORDS, PERFORMANCE EVALUATIONS,
DISCIPLINARY RECORDS, RATES OF PAY, REASONS FOR LEAVING, AND OTHER INFORMATION PERTINENT TO MY
QUALIFICATIONS FOR EMPLOYMENT. I HEREBY RELEASE THEM AND FAMILY CONNECTIONS FROM ANY AND ALL CLAIMS
AND LIABILITY FOR DAMAGE OF EVERY NATURE AND KIND ARISING FROM THE FURNISHING OF THE REQUESTED
INFORMATION.

(NOTE: YOUR PRESENT EMPLOYER WILL ONLY BE CONTACTED WITH YOUR CONSENT OR AFTER YOU HAVE GIVEN NOTICE
OF RESIGNATION.)
I FURTHER AUTHORIZE AND AGREE TO BE FINGERPRINTED IN ACCORDANCE WITH N.J.S.A. 30:6D-63 TO 72 TO
DETERMINE THAT NO CRIMINAL HISTORY RECORD EXISTS ON FILE IN THE FEDERAL BUREAU OF INVESTIGATION
IDENTIFICATION DIVISION, OR THE STATE BUREAU OF IDENTIFICATION IN THE DIVISION OF STATE POLICE.
I FURTHER UNDERSTAND THAT IF I RECEIVE AN OFFER OF EMPLOYMENT, MY EMPLOYMENT IS SUBJECT TO, AND
CONDITIONED UPON: (1) FAMILY CONNECTIONS INVESTIGATION OF THE WORK AND PERSONAL REFERENCES I HAVE
PROVIDED; (2) ALL CRIMINAL HISTORY AND BACKGROUND CHECKS APPLICABLE TO THE POSITION FOR WHICH I AM
APPLYING; AND (3) THE PROVISION OF MY FINGERPRINTS, IF APPLICABLE TO THE POSITION FOR WHICH I AM APPLYING. I
UNDERSTAND AND AGREE THAT IF I DO NOT COMPLY WITH ANY OF THE FOREGOING, OR FAMILY CONNECTIONS IS NOT
SATISFIED WITH THE RESULTS OF SAME, ANY OFFER OF EMPLOYMENT WILL BE RESCINDED.
I UNDERSTAND THAT SHOULD AN EMPLOYMENT OFFER BE EXTENDED TO ME AND ACCEPTED THAT I WILL FULLY ADHERE
TO THE POLICIES, RULES AND REGULATIONS OF EMPLOYMENT OF FAMILYCONNECTIONS. HOWEVER, I FURTHER
UNDERSTAND THAT NEITHER THE POLICIES, RULES AND REGULATIONS OF EMPLOYMENT OR ANYTHING SAID DURING THE
INTERVIEW PROCESS SHALL BE DEEMED TO CONSTITUTE THE TERMS OF AN IMPLIED EMPLOYMENT CONTRACT. I
UNDERSTAND THAT ANY EMPLOYMENT OFFERED IS FOR AN INDEFINITE DURATION AND AT WILL AND THAT EITHER I OR THE
EMPLOYER MAY TERMINATE MY EMPLOYMENT AT ANY TIME WITH OR WITHOUT NOTICE OR CAUSE.

APPLICANT SIGNATURE: _______________________________________

DATE: ________________

TO BE COMPLETED BY FAMILYCONNECTIONS:
EMPLOYMENT DESIRED:
ADMINISTRATIVE
CLINICIAN

DRIVER

MANAGER

INTERN

EXECUTIVE

SUPERVISOR
OTHER (EXPLAIN):

PROFESSIONAL

COORDINATOR