Please list employment including periods of education and military service.
  Employer’s Name: Supervisor’s Name Job Title: Start Date: End Date: Reason For Leaving:
1. Current Employer
2. Employer’s Name
3. Employer’s Name
4. Employer’s Name

Work References

  Name Of Reference Telephone Number Relationship
  Start Date End Date
Dates of CLA employment:
Conditions Of Employment
Information provided on this application and resume is true and complete to the best of my knowledge. Misrepresentation, falsification, or omission of facts will result in refusal or termination of employment.

My demonstrating, through a Community Living Association–paid physical examination or physical capacity Job Placement Assessment the ability to perform the essential functions of the offered position with or without reasonable accommodation and if I can demonstrate such a capability; and take two TB tests and annual TB test. Health information I provide for the assessment will be true and complete to the best of my knowledge. I authorize Community Living Association to inquire into my medical background as it affects my qualifications for employment and fitness for duty. I authorize any doctor, hospital, or medical facility from which I have received medical treatment of any nature to release to Community Living Association at their request any and all records regarding my medical history; and release and discharge persons or facilities so doing from any and all liability arising there from.

I understand and agree that my employment with Community Living Association, including my employment in any and all subsequent positions is “At Will” and may be terminated by me or Community Living Association at any time, for any reason, with or without cause, and with or without notice; no employment contract is being offered. I understand that no manager or representative of Community Living Association other than its CEO has any authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to the foregoing. I understand and agree that no oral or written representations, other than those contained in this Employment Application have been made to me with reference to my employment with Community Living Association and that this application constitutes the final, complete, and entire agreement between myself and Community Living Association on the subject of my employment.

I understand management, will make every effort to accommodate individual preferences; changing organization needs may require changes in job duties, working overtime, shift work, working different schedules, transfers to other departments or facilities; rejection by a client or reduction in state funding may result in my job being changed or eliminated; CLA can change wages, benefits, and conditions at any time.

I agree to adhere to all provisions of Community Living Association’s policies and procedures that apply to my position and further understand that Community Living Association may amend those provisions at any time, as it deems appropriate in its sole discretion. In no event, however, shall these policies and procedures be construed to alter my right or the right of Community Living Association to terminate my employment at any time, for any reason, with or without cause.

FCRA Disclosure and Authorization Statement
As part of its employment application process, I understand that Community Living Association (CLA) may obtain or have prepared a consumer/investigative consumer report concerning my prior employment, military record, education, character, general reputation, personal characteristics, or criminal background.

I understand that upon written request to CLA, I will be informed whether an investigative consumer report was requested, and given full information as to the nature and scope of such investigation. I understand that an investigative consumer report is a report in which information regarding my character, general reputation, or personal characteristics is obtained through personal interviews with neighbors, friends, or associates with whom I am acquainted.

I authorize CLA to obtain a consumer/investigative consumer report on me as part of its pre-placement background investigation process.

If I am offered employment, I further authorize CLA to obtain additional consumer/investigative consumer reports on me for employment purposes at any time during my employment.

Consent to Disclose Information
In compliance with public law 91-508, I authorize CLA to investigate my employment history and verify all information given in my application, related materials, references, and interviews, including but not limited to: character, work habits, job performance, experience, credentials, criminal background, sex offender, and motor vehicle driving record checks; check for DHHS child/adult/client abuse, neglect or punishment from any state, court, or agency. I understand this is a federal requirement for applicants to work with CLA clients; and continued employment is contingent upon pre-placement physical assessment and background investigation.

I authorize and release from liability anyone giving or receiving information during this investigation. I understand that falsification and negative information so given or discovered may prevent my employment with or result in immediate dismissal from CLA. I understand that information obtained is confidential.

This certifies that this application was completed by me; that all entries are true and complete to the best of my knowledge; I understand and agree to all the preceding provisions. I certify that I am a genuine applicant for employment and submitting this application solely for the purpose of seeking employment with Community Living Association. By signing below, I acknowledge that CLA has provided me with a summary of my rights under the conditions of employment, Fair Credit Reporting Act, and consent to disclose information.