Employment The LandingCC Employment Application The LandingCC Employment Application PERSONAL INFORMATION NAME ADDRESS CONTACT DETAILS EMAIL ADDRESS Position Desired (Work Preference): Check One: Administration office caregiver Therapist Are you available to work: Full-Time? Yes No Part-Time? Yes No Evenings? Yes No Weekends? Yes No Overtime? Yes No What days and hours are you available to work? How did you hear about Prairie Harbor? Educational Information: Highest Grade Completed ---123456789101112graduatepost_graduate Did you graduate High School and have a transcript or diploma? Yes No Other Special Training and/or Certifications: Can you read and write English? Yes No Miscellaneous Information: Do you have any friends, relatives, or acquaintances working for The LandingCC ? Yes No If yes, state name & relationship: Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No If yes, please describe the crime(s), state nature of the crime(s), when and where convictedand disposition of the case Are you aware of any reason(s) which would prevent you from consistently performing the specific duties necessary to do the job for which you have applied? Yes No If yes, state name & relationship: Are you using any medication which would affect your ability to perform the specific duties necessary to the job for which you have applied? Yes No Do you have reliable transportation? Yes No All The LandingCC employees are required to be drug-free as a condition of employment, and must submit to an initial and subsequent random drug testing. Would you be willing to submit a drug test for employment reasons? Yes No How much time have you lost from work during the past twelve months? For what reason(s)? Employment History: (Give complete record of business or employment for past seven years.) Employer Phone# Supervisor From-To Duties What was the reason for leaving your last employment? May we contact this employer? Yes No If presently employed, how much notice to present employer is necessary? Have you ever worked with children? Yes No If present In what capacity? In your own words, please write a brief explanation of why you want to be employed by The LandingCC : Professional References: (List below three persons who have knowledge of your work performance within the last four years. Please include professional references only .) Name Address Phone# Occupation #YearsAcquainted I certify that the foregoing information is true and correct to the best of my knowledge, and I understand that any misrepresentation or willful omission of facts shall be cause for rejection of this application or termination of employment I hereby authorize The LandingCC to conduct a work history reference check to determine my acceptability for employment. I further agree to hold The LandingCC and any former employer I have provided, harmless concerning any information or the use of any information furnished by the reference. Pursuant to Texas Education Code, Section 21.917, I hereby authorize The LandingCC to obtain a Driver’s License check and any criminal history record information pertaining to me from any law enforcement agency. I further agree to observe all rules, regulations, and policies of The LandingCC .