Name
*
First Name
Last Name
Position Applying For
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
(###)
###
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Do you have a valid driver license
*
Do you have Liability Insurance
*
Do you have a clean driving record
*
If no, please list traffic offenses, accidents, etc. and the dates they occurred. *This information does not disqualify you for employment. If Yes, please type N/A in the box below
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Are You Currently On Any Medication That Could Impair Your Driving Judgement?
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Are You Currently Employed?
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If presently employed, why do you desire to change your position?
On what date will you be available for work? Provide specific.
*
MM
DD
YYYY
Are you available to work:
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Have you ever been convicted, forfeited bond, are you currently on probation for any felony, or any equal offense under military law? (A felony is defined as an offense punishable by imprisonment for a term of one year or greater.)
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Are you currently under any investigation or pending charge?
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Are you currently on probation or parole?
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If yes, give details for each felony offense. Include (1) date, (2) charge, (3) place, (4) court, and (5) action taken. You must disclose any felony conviction involving a sentence or a suspended sentence. You may omit: (1) any offense committed before your 18th birthday which was finally adjudicated in juvenile court; (2) any conviction which has been expunged under federal or state law. A conviction will not necessarily disqualify you from the job for which you are applying. A conviction will be judged on its own merits with respect to time, circumstances, and seriousness.
Education and Training:Name of School and City/State:
Major Field of Study/Area of Concentration/ Did you graduate?
Type of Degree or Certificate Earned: (Include Month/Year)
Special Qualifications- Use the following space to list any active technical/professional licenses and number, academic or professional awards, special skills or trainings such as Medication Administration, CPR/First Aid, PCM, Protection from Harm, Intro to MR/DD, etc. Please note the training and date it was completed.
Are you presently a member of the Army National Guard/Reserves or do you have any other military obligations?
Employer #1
*
Employer #1 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer #1 Phone
*
(###)
###
####
Dates of Employment: (Month/Year)
*
Job Title:
*
Summary of Job Duties:
*
Reason for Leaving:
*
Employer #2
*
Employer #2 Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer #2 Phone
*
(###)
###
####
Dates of Employment: (Month/Year)
*
Job Title:
*
Summary of Job Duties:
*
Reason for Leaving:
*
Reference
*
Reference Phone
*
(###)
###
####
Reference Email
*
Reference Relationship
*
Have you ever been involved in a state investigation that had been either substantiated or unsubstantiated?
*
If Yes, Explain
I, the undersigned applicant, certify and affirm that, to the best of my knowledge and belief; I [“have” or “have not,” as applicable] had a case of abuse, neglect mistreatment, or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation, I further release and authorize Envision, Inc., The Tennessee Department of Intellectual and Developmental Disabilities and the Bureau of TennCare to have full and complete access to any and all current or prior personnel or investigative records, form any party, person, business, entity or agency, whether governmental or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment or exploitation and to consider this information as may be deemed appropriate. This authorization extends to providing any applicable information in personnel or investigative reports concerning my employment with this employer to my future employers who may be Providers of DIDD services.
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Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
