APPLICATION for EMPLOYMENT

First Name

Middle Initial

Last Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Preferred Method of Contact:

Home Phone Cell Phone Email Other

In Case of Emergency, I authorize You to Contact:

Name

Telephone Number

Exceptional Case Services Is An Equal Opportunity Employer

Applications are received and employees are hired without regard to race, sex (including pregnancy, sexual orientation, gender identity, and gender expression) religion, age, national origin, color, marital status, disability or handicap, genetic information, veteran's status, citizenship status, or any other protected class under state, local, or county regulations. The receipt of this application does not mean that job openings exist and does not obligate us in any way. We appreciate your interest in our organization.

THIS IS A DRUG-FREE WORKPLACE

What position are you applying for?

What is your salary expectation?

When can you start work?

How were you referred to us?

Have you completed an application with us in the past?

Yes

If yes, date/location?

Have you been employed here before?

Yes

If yes, date/position/location?

Are you available to work (Check all that apply):

Full Time

Part Time

Temporary

Nights

Weekends

Are there any days or times during the week that you are not available to work

Yes

If yes, please list the day/times you are not available to work?

If necessary, can you provide proof that you are over any minimum work age requirement?

Yes

Are you willing to work overtime?

Yes

Do you have steady transportation to work?

Yes

If you are applying for a medical consultant position, can you travel if required?

Yes

How often are you willing to travel?

Are you on a layoff and subject to recall?

Yes

May we contact your present employer?

Yes

How much time have you lost from work during the past 12 months?

Are you now, or do you expect to be, engaged in any other business or employment while working here?

Yes

If yes, please explain:

Are you presently an officer, employee, or employer of another business in our industry or with whom we compete?

Yes

If yes, please explain:

Are you currently subject to a Non-Compete Agreement or Restrictive Covenant that would prohibit you from working at our company in the position for which you are applying?

Yes

If yes, please provide a copy of the agreement and state the name of the company:

Have you ever been terminated or asked to resign from a job?

Yes

If yes, please explain:

Why do you desire to make a change?

Are you legally eligible to work in the United States?

Yes

(Proof of eligibility/identity required upon hire)

What three things are most important to you in a job?

What three adjectives best describe you?

What type of work do you most enjoy?

Why do you want to work here?

High School or GED

Did you graduate?

Yes

Degree Received and Major Subject

Years Completed

School Name

School Location

Trade, Business, or Correspondence

Did you graduate?

Yes

Degree Received and Major Subject

Years Completed

School Name

School Location

College

Did you graduate?

Yes

Degree Received and Major Subject

Years Completed

School Name

School Location

Graduate School

Did you graduate?

Yes

Degree Received and Major Subject

Years Completed

School Name

School Location

List any special skills, training, or experience that may be relevant to this position or our company

List any professional, trade, business, or civic activities that would relate to working here

List any foreign languages that you frequently speak, read, and/or write that would relate to working here

List software programs that you are proficient in

Please indicate any active (unexpired) medical licenses or certifications that you have:

CDMS

COHN

CRRN

ABQAURP

CCM

Board Certified in Case Management

Vocational and other credentials

Do you hold a valid and unexpired Driver's License that is not currently suspended or revoked?

Yes

If yes, please provide the state:

Have you been convicted of any moving violation(s) in the last 5 years?

Yes

If yes, give date(s) and explanations of each:

Branch of Service

Rank at discharge, if applicable

From:

To:

List Duties and Special Training and/or Skills

Have you ever been convicted of, received a sentence for, pled nolo contendere (no contest) to, been placed on probation, or finded by any judicial or quasi-judicial body for a crime, other than a minor traffic violation? NOTE: Answering "yes" to this question is not an automatic bar to employment. Arrest records and juvenile, sealed, and expunged records should not be disclosed. Any other criminal record not disclosed by you may be considered falsification of this application, which may result in revocation of your employment over or termination of your employment. Also, in accordance with any state or federal regulations, you may be required to provide copies of any criminal records.

Yes

If yes, describe the details of the conviction/offense, the sentence for the conviction/offense, the date of the conviction/offense (month and year), and your rehabilitation since then:

NOTE: Answering "yes" to any of these questions is not an automatic bar to employment.

Have you ever been disciplined or terminated from any job for an act of violence, harassment, discrimination, ethical breach or theft?

Yes

If yes, explain the circumstances, employer and date:

Have you ever been a defendant in a civil action for an intentional tort? (e.g., assault, battery, false imprisonment, infliction of emotional distress, tortuous interference, with a business relationship, defamation, invasion of privacy, fraud and misrepresentation, abuse of process and malicious prosecution or others)

Yes

If yes, provide an explanation of the nature of the intential tort, the date of action, the location, and the disposition or outcome:

Have you ever had any license or certification suspended or revoked?

(e.g., real estate license, driver's or boater's license, etc.)

Yes

If yes, give date(s) and explanations of each:

Employment History 1

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Employment History 2

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Employment History 3

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Employment History 4

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Employment History 5

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Employment History 6

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Employment History 7

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Employment History 8

Employer

Address (City, State, Zip)

Job Title

State Reason

Resigned

Terminated

Dates Employed

From (Mo/Yr)

To (Mo/Yr)

Phone: (Include Area Code)

Hourly Rate, Weekly Salary, or Other Weekly Earnings

Starting

Final

Summary of Work Performed and Job Responsibilities

Supervisor's Name

Agreement and Release

The facts set forth above in my application for employment are true and complete. I understand that false statements or omissions of information on this application (even if discovered after employment) or any other employment form may lead to dismissal or denial of employment. If required, I agree to submit to any drug or alcohol testing prior to or after employment. I understand that submission of this application does not imply that I will be hired.

I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record.

I understand that if my application is accepted and if I am hired, that employment with Exceptional Case Services, Inc. is employment "at will." It is further understood that this "at will" relationship may not be changed by any written document, verbal statements, or by conduct unless an authorized executive of Exceptional Case Services, Inc. specifically acknowledges such change. I further understand that my "at will" employment may be terminated at any time by me or Exceptional Case Services, Inc. and includes no guarantee, contract, or promise of employment for any specific length of time. I understand that the first 90 days of employment is a new-hire introductory period.

I have read, understand, and by my signature consent to these statements.

Signature of Applicant

Date

State and/or federal regulations are subject to change at any time; therefore, the questions on this form are subject to exceptions and qualifications. The author does not bear responsibility for ensuring this form is up to date and compliant with state, federal, or local employment regulations. If in doubt, seek assistance from a qualified expert. Also, the author is not responsible for any unauthorized changes or omissions to the form.

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APPLICATION for EMPLOYMENT

Exceptional Case Services Is An Equal Opportunity Employer

THIS IS A DRUG-FREE WORKPLACE

High School or GED

Trade, Business, or Correspondence

College

Graduate School

Agreement and Release

Contact Us