* = Required Information
CentrePoint Support Living is an equal opportunity employer. It is the policy of CentrePoint Support Living not to discriminate on the basis of race, sex, religion, marital status, age, weight, height, color, disability, or veteran status in hiring.
(Answering “yes” to this inquiry will not automatically disqualify you)
High School
College / University
Specialized Training, Trade School, etc.
Other
Dates
Dates
Dates
Reference 1
Reference 2
Reference 3
I hereby give you my permission to conduct the above employers, references, and educational, licensing, credential and certification institutions to verify the items I listed above. I hereby release CentrePoint Support Living and the above referenced organizations, reference personal and employers from all claims, liability and damages that may result from furnishing the information to you. I consent to releasing any information relating to my job performances which is documented in my personal file. In the event that a prior employer or other organization is obligated to provide any written notice to me regarding the disclosure of information to CentrePoint Support Living I hereby waive that obligation except no written notice of disclosure of any personal information.
I also understand that because of the nature of my job and licensing requirements, I hereby consent to the release of this application or portion of the application representatives of the Department of Human Services, Department of Community Health, Local Community Mental Health entities or other governmental Agencies or private agencies, for all licensing or investigatory purposes and to verify information I have given in this job application. I hereby release CentrePoint Support Living, The Department of Human Services, and Department of Community Health, Community Mental Health entities or other government Agencies or private agencies, from all claims, liability, and damages that may result from furnishing the information to you.
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 any prior employers from all claims, liability and damages that may result from furnishing the information to you.
I certify that all information provided on this application is true, complete and correct.
I further understand and agree that any falsification, misrepresentation and omission of fact on this application or in any interview or pre-employment process and grounds for disqualification for consideration for employment or termination of employment if the discovery is made after employment begins.
In consideration of my employment, I agree to conform to the policies, rules and regulations of CentrePoint Support Living. I understand and agree that my employment and compensation are for no definite period and, may regardless of the time and manner of my wages or salary, be terminated at-will with or without cause and with or without notice at any time, at the sole discretion of CentrePoint Support Living or myself.
