COMMUNITY LIVING CONCEPTS-NC, INC.
433 South Meeting Street, Statesville NC 28677 - (704) 838-0016 - Fax (704) 838-0019
Dear Applicant:
Thank you for your interest in Community Living Concepts-NC. We are a private, non-profit provider of 24-hour residential services for persons with varying developmental disabilities and mental health needs. We have been providing services in North Carolina since March, 1993, and now have many work sites scattered across the state.
We recognize that those we hire become a reflection of the organization as a whole. We take pride in hiring persons who have the qualities necessary to carry out the responsibilities of the job and who carry a positive attitude. We compete a thorough background check on everyone we hire through a face-to-face interview, reference checks, criminal background and driving record checks. This application contains forms that require completion before a job offer is made, and include the following:
Community Living Concepts-NC, Inc. Job Application
Three references (two professional and one personal reference)
Criminal Background Check Form
Driving Record Check Form
NC Personnel Healthcare Registry Check Form
Please complete the information and return to the Statesville or nearest regional office. Once received, we will review your application and contact you to arrange an interview should you meet qualifications for the position applied for.
Thank you for your interest in working with Community Living Concepts-NC, Inc.
Community Living Concepts-NC, Inc. Job Application
We are an equal opportunity employ. It is the policy of this organization not to discriminate on the basis of race, religion, national origin, marital status, age, sex, sexual preference, weight, height, color, or handicap in the hiring, training, scheduling, transfer, promotion, payment, or discipline of employees.
We will not discriminate against a person with a covered disability under the Americans With Disability Act in regard to employment practices or terms, conditions, and privileges of employment.
Date of Application: __________
Name: _________________________ S.S. Number: _________________________
(copy required for employment)
Address: _________________________ City: _________________________
State: __________ Zip Code: __________ Phone: _________________________
How long have you lived at this address: __________
Do you currently have a valid driver's license: Yes __________ No __________
License Number: __________
Expiration date: __________ (copy required for employment)
Are you 18 years of age or older: __________
Position applied for: _________________________
Area applied for: _________________________
Can you physically and mentally perform the duties of the job as described with or without accommodation?
Yes __________ No__________
We are licensed to provide supports for persons with varying disabilities 24 hours a day, 365 days a
year. Working overtime hours is at times expected. Are you willing to meet this requirement?
Yes__________ No__________
Have you ever been convicted of a crime: Yes__________ No__________
If yes, please explain: ______________________________________________________
Are there any felony charges pending against you: Yes__________ No__________
If yes, please explain: _______________________________________________________
Have you ever been administratively determined to have committed abuse or neglect:
Yes __________ No__________
If yes, when, where, and nature of the case: ______________________________________
___________________________________________________________________________
___________________________________________________________________________
Have you ever been employed by this organization before: Yes__________ No__________
If yes, give dates employed and indicate if employed under a different
name: _________________________
Do you know anyone who currently works for CLC-NC: Yes__________ No__________
If yes, who: ____________________________________
In case of emergency, whom should we contact? ________________________________
Phone: ( ) _________________
EDUCATION
High School Attended: ___________________________________________
City/State: ________________________________
Year Graduate:_____________ GED:_____________
ADDITIONAL EDUCATIONAL/CERTIFICATIONS
School/Address Courses Taken Degree Year Graduated
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
EXPERIENCE - LIST MOST RECENT EMPLOYER FIRST
Employer Address Job Title Dates Reason Left
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
References - Please provide the two professional and one personal reference
Name Agency Address Phone Number Relationship
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
BACKGROUND CHECK INFORMATION
Last Name: ______________________ Maiden Name:______________________
First Name: ______________________ Middle Name: ______________________
______ Check here is maiden name is used as middle
Birthdate: ______________________ Social Security Number: _______________
Drivers License Number: ____________________ State of Issue: ________________
Drivers License Number: ____________________ State of Issue: ________________
Drivers License Number: ____________________ State of Issue: ________________
Present Address: _____________________________ County: ____________________
_____________________________
Previous Address: _____________________________ County: ___________________
_____________________________
Previous Address: _____________________________ County: ___________________
_____________________________
I hereby give CLC-NC permission to contact the above employers, references, and educational institutions to verify the items I listed above. I hereby release CLC-NC and the above referenced organizations, reference persons and employers from all claims, liability, and damages that may result from furnishing the information. I expressly and fully waive all written notice from all prior employers. I also understand that because of the nature of my job and State licensing requirements, I hereby consent to the release of this application or portions of this application to representatives of governmental agencies as may be required by regulation or federal law.
I further specifically waive written notice and agree to the divulging of any disciplinary reports, letters of reprimand or other disciplinary action by all prior employers and hereby release my prior employers from all claims, liability, and damage that may result from furnishing this information to CLC-NC.
_________________________________________ ________________________
Applicant Signature Date
Applications remain on file for six months