I. Personnel Information
Name *
Name
Address *
Address
Phone Number *
Phone Number
Type of Phone Number *
II. Background
Education *
Check all completed.
(Electrical, mechanical, plumbing, etc.)
Please include job title.
III. Times available to volunteer
Specify time under each day
IV. Reference #1 *
IV. Reference #1
Phone *
Phone
Reference #2 *
Reference #2
Phone *
Phone
V. Emergency Contact *
V. Emergency Contact
Address *
Address
Phone *
Phone
VI. Questions of Record
Sheltered Living, Inc. Applicant Authorization to Release Information
I AUTHORIZE SHELTERED LIVING, INC. TO CONTACT ANY COMPANY, INSTITUTION, LAW ENFORCEMENT AGENCY, STATE AGENCY, BUREAU OR INDIVIDUAL IT DEEMS APPROPRIATE TO INVESTIGATE MY EMPLOYMENT HISTORY, JOB PERFORMANCE, BACKGROUND, QUALIFICATIONS, DRIVING RECORD AND OTHER RELEVANT INFORMATION, IF JOB RELATED. I GIVE MY FULL CONSENT FOR ALL CONTACTED PERSONS INCLUDING FORMER EMPLOYERS TO PROVIDE THE INFORMATION CONCERNING THIS APPLICATION, I WAIVE MY RIGHT TO BRING ANY CAUSE OF ACTION AGAINST THESE INDIVIDUALS FOR ANY AND ALL LIABILITY FOR DAMAGES ARISING FROM FURNISHING THE REQUESTED INFORMATION TO THE COMPANY.
Name *
Name
Date *
Date
Birthdate *
Birthdate
SHELTERED LIVING, INC. CURRENTLY VERIFIES INFORMATION WITH: -KANSAS BUREAU OF INVESTIGATION - SOCIAL AND REHABILITATION SERVICES - CHILD ABUSE AND NEGLECT - MOTOR VEHICLE REPORT - KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT - SHAWNEE COURT RECORDS - OTHER LOCAL, STATE AND NATIONAL DATABASES AND PUBLIC INFORMATION SYStems
ACCORDING TO THE FAIR CREDIT REPORTING ACT, APPLICANTS ARE ENTITLED TO KNOW IF INSURANCE OR EMPLOYMENT IS DENIED BECAUSE OF INFORMATION OBTAINED BY THE PROSPECTIVE EMPLOYER FROM A CONSUMER-REPORTING AGENCY.