Application for Contracted Services

Transcription

1 PERSONAL INFORMATION Application for Contracted Services Last Name First Name Middle Name Address Apt# City State Zip Home Phone Cell Phone _Address Social Security Number Date / / What type of work would you like to provide? How did you learn about Family of Faith Service Providers? Family of Faith website Walk in Advertisement Employment Agency Relative Other Have you ever filed an application with us before? If yes, give date YES NO Have you ever been arrested? If so, please explain. YES NO Arrest will not necessarily disqualify a contractor from providing services Have you ever been convicted or pleaded no contest to a felony or misdemeanor charge? YES NO If yes, please explain. Conviction will not necessarily disqualify an applicant from employment. Have you ever been indicated or founded on a child abuse charge? YES NO If yes. Please Explain.

2 EDUCATION High School Name and Location of School Course of Study or Major Number of years Complete Diploma/Degree Awarded? Undergraduate College Graduate/Professional Other (specify) Indicate any foreign Languages you can speak, read, and/or write Speak Read Write Describe any specialized training, apprenticeship, skills, extra-curricular activities or special skills. Describe any job-related training received in the United States Military. Describe any additional information that you would like to include. (i.e. personal testimony, personal mission, et

3 Personal references that speak to your Character Name Address Phone Number Relationship/Occupation Years Known 1) 2) 3) Personal references that speak about your Faith Name Address Phone Number Relationship/Occupation Years Known 1) 2) 3)

4 Applicant s Statement Please read carefully before you sign * I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application including driving record and criminal background check, as it may be necessary at a decision for approval of volunteering time and services. I hereby acknowledge that, unless otherwise defined by applicable law, any services performed at Family of Faith Service Providers is voluntarily entered into for an indefinite period of time. It is further understood that no employment relationship is intended and no compensation will be received for any volunteer work or services rendered. If selected as a contractor, I understand that false or misleading information given during the selection process may result in discharge. I understand, also that I am required to abide by all rules and regulations of Family of Faith Service Provider. I also affirm that I have been advised in the event I provide contract services, and the criminal or driving record comes back with an unallowable result, I understand that my services will be duly terminated. BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENT. Applicant s Signature Date

5 REQUEST FOR CRIMINAL HISTORY AND CENTRAL REGISTRY CHECK APPLICATION SOCIAL SECURITY NUMBER Drivers license or state identification number State ID type (DL or ID card) First Name Middle Name Last Name Address City State Zip County Telephone Date of Birth Gender M F Position Appling For: Staff Licensed Administrator Contractor Date hired (Used by the operations agent only) Other names used (married, maiden etc.) First Ethnicity (must accompany race) Hispanic other Middle Race White African American Asian/Pacific islander American Indian Last Have you lived in any state other than Texas? Yes No I consent to Family of Faith Service Providers this background check. Signature Date Print Name