Employment Application

Dear Applicant:

Thank you for your interest in ComServ, Inc. We are a private, non-profit agency dedicated to the development and operation of programs and services that meet the individual needs of the people we support.
To be eligible for employment, you must meet the minimum requirements and provide us with:

* A completed Application for Employment
* A valid driver’s license from the state in which you reside
* A good driving record which meets the criteria defined by ComServ’s liability insurance carrier
* Evidence of educational achievements (minimum: GED or high school transcript)
* Evidence of being drug free through pre-employment drug screening
* A statewide and/or national criminal record check to include the Sex Offender Registry from the states in which you have resided within the past five years
* Federal Exclusion Check (Office of the Inspector General, OIG, provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other Federal health care programs).
* A North Carolina Health Care Registry Report with no substantiated findings of abuse or neglect

Meeting these requirements does not mean that you will be employed, only that you meet the minimum requirements to be eligible for employment at ComServ. If you are chosen for interview and offered employment, you will need to:

Authorize ComServ to conduct a background check
Provide proof of eligibility for employment in the United States (drivers license, social security card)
Pass or produce evidence of a negative TB test (paid for by ComServ)

Please note there is no guarantee of a job offer or a job interview in completing our application. Your application will be considered with others who have submitted applications, and decisions about interviews will be based on this comparison to determine the applicant best qualified for the position.

Your employment application must be completed and legible in order for it to be considered. If the information you provide on your application cannot be satisfactorily verified by employment reference checks based on information you have supplied, your application will be considered incomplete. Due to the large number of applications we receive and the competitive nature of your employment process, specific reasons for employment decisions will not be released.

I have read the information above pertaining to ComServ's eligibility requirements for job applicants and understand that I must meet these minimum requirements in order to be considered for employment. *

First Name

Middle Name

Last Name

What type of employment are you interested in *

Full-Time

Part-Time

Position(s) Applied

Direct Support- Residential

Direct Support Day- Activity

Other

Location applied for

Please share with us how you heard about our job vacancies: *

Indeed

ComServ Website

Employee Referal (If referal, please specify in "other" )

NC Works

Community College Job Boards

Other

ComServ, Inc.
Application For Employment
PO Box 1080 * Lenoir, NC 28645 * 828-757-0209

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, marital or veteran status, the presence of a non-job related medical condition or disability, or any other legally protected status. *

First Name

Middle Name

Last Name

Date *

YYYY

Address

City

State

Zip

Home Phone Number

Cell Phone Number

May we text you?

yes

Phone Number

What hours and days can you work? (Specify Shifts available and days) *

Have you ever applied here before? *

If you have previously worked for a Comserv Inc location, Please specify dates : *

Are you related by blood or marriage by to any person now working for Comserv Inc? if yes, Whom? *

Are you currently working?

yes

Have you had any Job Related training in the US military? If yes please describe: *

Have you been a resident of the State of North Carolina for the past five years? If no, please specify where you have been a resident for the past 5 years. *

Education: *

High School or Name of Institution *

Location of High School or Institution where diploma or GED was received *

Did you graduate? *

yes

Dates attended or graduated (mo/yr) *

Type of degree received

College(s) or University (s)

Did you graduate?

yes

Type of degree received

Other educational, Vocational school

Did you graduate?

yes

Type of degree received

Graduate or Professional School

Licensure/Certifications

Certification or License Description and #

Did you graduate?

Yes

Type of degree received

PERSONAL REFERENCES: must not be relatives or previous employers *

First Name

Last Name

Phone Number *

Address

City

State

Zip

PERSONAL REFERENCES: must not be relatives or previous employers *

First Name

Last Name

Address

City

State

Zip

Phone Number *

PERSONAL REFERENCES: must not be relatives or previous employers *

First Name

Last Name

Phone Number *

Address

City

State

Zip

Check the following skills, experiences, etc which you may have

Sign Language

Office Equipment

Computer Skills

Foreign Languge

Braile

Other

HEALTHCARE SKILLS AND QUALIFICATIONS

WORK HISTORY- Name of Employer (you may include volunteer experience) *

May we contact this employer *

Yes

Job Title *

Date Employment Started (mo/yr) *

YYYY

Date Employment Ended *

YYYY

Phone Number *

Address

City

State

Zip

Number Supervised by you

Starting Salary

Ending Salary

List major duties in their importance of the job:

WORK HISTORY- Name of Employer (you may include volunteer experience) *

May we contact this employer *

Yes

Job Title *

Date Employment Started (mo/yr) *

YYYY

Date Employment Ended

YYYY

Phone Number *

Address

City

State

Zip

Number Supervised by you

Starting Salary

Ending Salary

Reason for Leaving

List major duties in their importance of the job:

WORK HISTORY- Name of Employer (you may include volunteer experience) *

May we contact this employer

Yes

Job Title *

Date Employment Started (mo/yr) *

YYYY

Date Employment Ended *

YYYY

Phone Number *

Address

City

State

Zip

Number Supervised by you

Starting Salary

Ending Salary

List major duties in their importance of the job:

Consent and acknowledgement for a Criminal Records Check ______

Consent to check references from previous employers ______

Consent and acknowledgement for a Health Care Registry Check ______

Consent and Acnowledgement for a Federal Exclusion Check

Consent and acknowledgement for a Motor Vehicle Report (MVR) ______

Consent and acknowledgement for Social Security Tracking ______

Consent and acknowledgement for pre-employment drug screening and random drug screening thereafter.______

Consent and acknowledgement for a Sex Offender Registry Check ______

Applicant’s Statement and Memorandum of Understanding:

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview (s) may result in discharge.

I understand, also, that I am required to abide by all rules and regulations of the employer.

1. The applicant knows that references, Health Care Registry, Criminal Background, Federal Exclusion, Social Security Tracking, Motor Vehicle Report, Sexual Offender Registry and education checks will be performed, as well as a pre-employment drug screening and random screening thereafter.

2. The applicant has initialed the items that require verification and by his/her witnessed signature has given permission for the verification to be completed by a member of the Human Resources Department Staff.

3. The information released to ComServ, Inc. will not be used for any violation of federal, state, or local
employment laws. *

First Name

Middle Name

Last Name

Pre-Employment Inquiries Release and Consent Form

In connection with my application for employment, or contract to provide services on behalf of this agency, I understand and consent that investigative background inquiries will be made on me to include criminal, driving, experience, education and general character. I further understand that this agency will be requesting this information from previous employers, various federal, state, or other agencies which maintain records concerning my past activities relating to my driving record and any criminal convictions.

In accordance with NC GS 114-19.10, if I have not been a resident of the State of NC for the past five (5) years as of the date of the application, it is understood that the investigation will include my fingerprinting to be submitted for a national criminal history record check. I also understand that any offer of employment made will be contingent upon verifying the non-existence of a criminal record that would disqualify me from employment in the position for which I have applied.

I authorize, without reservation, any party or agency contacted by ComServ, Inc. to investigate my past record and to access any and all information which may concern my record and character, whether same is of record or not.

The Following Information Will Be Used To Run the Criminal Background Check

Any Other Names Used/Maiden Name

First Name

Middle Name

Last Name

Address

City

State

Zip

Years of Residence in NC *

Previous Address

City

State

Zip

State that Issued Current Driver's License/ Include Driver's License # *

First Name

Last Name

Today's Date *

YYYY