Application :: Full Automated Staffing Solutions

Your Name

Your Email Address

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Direct Support Professional Part Time

Direct Support Professional Full Time

As Needed (PRN) Position

Master-Level Behavior Specialist

Program Director

Part-Time Director Assistant

Certified Nursing/Registered Nurse/LPN

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Address (street)

Address (city, state, zipcode)

Social Security Number

Phone Number

Date of Application Submission

Have you ever applied to Umbrella FCST?

Yes

No

Don't Know

Are you prevented from legally becoming employed in the USA because of VISA or immigration status? (Proof of citizenship or immigration status will be required upon employment)

Yes

No

Do you have a current Valid Driver License? If so What State?

Do you have your own vehicle?

Yes

No

Have you been a PA resident the last 3 years?

Yes

No

Have you ever been terminated or disciplined by a prior employer in connection with an allegation of client abuse or neglect? If YES, explain.

Are you the perpetrator of a founded report of child or adult abuse committed within the five-year period preceding this application? If YES, explain.

Are you physically able to perform the duties of the job for which you are applying?

Yes

No

Highest Level of Education you have completed and earned a degree or diploma?

High School Diploma or equivalent

Bachelor's Degree

Master's Degree

Graduate Certificate above a Master's

Doctorate

Trade School (college level)

None

What was the field of study for the highest level of education you've completed?

Describe any specialized training, internships, skills, and extracurricular activities:

Have you ever had any job-related training while serving in the United States Military? If YES, What was your training

Special Skills and Qualifications from employment or other experience:

Employment Experience: Have you ever worked in human services with adults or children before?

May we contact previous employers on your resume?

Yes

No

Hourly rate you received at your last job in the same position you are applying for now?

Work Performed in your previous employment

Reason for leaving your previous employment?

Dates of employment: From date:

Dates of employment: To Date:

If you do not wish us to contact any of the previous employers list the name of the employer you do not wish us to contact.

Reference 1: Supply the name and phone number of a professional reference who is not related to you and is not a previous employer.

Reference 2: Supply the name and phone number of a professional reference who is not related to you and is not a previous employer.

Reference 3: Supply the name and phone number of a professional reference who is not related to you and is not a previous employer.

I agree to the processing of my personal data for employment purposes

I certify that the answers given herein are true and completely correct to the best of my knowledge. I authorize investigation of all statements contained in this application for employment, as it may be necessary to arrive at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. I hereby acknowledge that any employment relationship with Umbrella FCST is of an "at will" nature, which means that the employee may resign at any time from Umbrella FCST, and that Umbrella FCST may discharge that 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 Umbrella FCST. In the event of employment, I understand that false or misleading information given in my application or interviews may result in discharge. I understand that I am required to abide by all rules and regulations of Umbrella FCST.

Umbrella FCST is a drug-free workplace and as such shall drug test all employees under suspicion of druve use is prevelent. All employees, as a condition of employment will be required to participate in drug and alcohol testing procedures at any time during employment in the event of suspicion, post-accident, and following incidents that involve the health and safety of individuals served. Though drug and alcohol testing is not required pre-employment, it will be required during employment with Umbrella FCST in accordance with this Drug and Alcohol Testing Policy. Umbrella FCST employees shall test negative for all illegal substances, and this testing is at the discretion of the company Umbrella FCST. All testing will be conducted by a licensed independent laboratory or primary care physician at the employee's choice and expense. The employee shall require this documentation as part of the employee's condition of employment. The substances will be tested include but are not limited to the following: Cannabinoids (THC), Cocaine, Phencyclidine (PCP), Amphetamines (including methamphetamines), Opiates (morphine, codeine, heroin), Barbiturates, Benzodiazephenes, Methadone, Methaqualone (Quaaludes), Propoxyphene (Darvon/Darvocet), and Excstasy. Testing for the presence of these substances will be conducted by analysis of urine. Applicants shall check the box provided signifying his/her/their consent to drug testing as a condition of employment and their understanding of this policy. Any employee who's urine specimen tests positive, or who is suspected of having drug and alcohol use and/or abuse shall be suspended from duty during which time shall furnish proof of additional efforts required to remain employed at the decision of the employer. These shall be discussed and agreed upon between the company's executive director. An employee must pass the drug test to be considered for removal from suspension. Any employee who refuses to undergo drug testing, or applicant who does not agree to the Drug and Alcohol testing policy, or employee who fails to produce results of testing procedures will not be employees of Umbrella FCST. An employee who obstructs the testing process in any way shall be deemed to have failed to complete the testing procedures and will no longer be eligible for employment through fault of his/her/their own.

I understand that being hired with Umbrella is provisional and I must complete certification requirements in accordance with state law.

yes

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