Inspiring success for today’s youth.”
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Employment Application



  • Section 1 (Basic Information):


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

  • Position(s) Applied For:

  • First Name:
    MI:
    Last Name:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Phone:
    Contact Preference:
    E-mail:

  • Do you have a valid driver's license?:



  • Have you ever filed and application with us before?:



  • If yes, give date:

  • Are you at least 20 yrs. old (0r 25 for Transitional Living)? :



  • Are you prevented from lawful employment in the United States due to visa or immigration status?:



  • Are you available to work overtime?:



  • Can you travel if your job requires it?:



  • Are you currently on probation or parole?:



  • On what date would you be available for work?:

  • Are you currently employed?:



  • May we contact your present employer?:



  • If no, explain:

  • Do you have any relatives employed by YSS?:



  • How did you hear about this job opportunity?:

  • If Referred, enter name:

  • When are you available to work?:




  • Preferred Shift (Check all that apply):





  • If there are any accommodations that will be needed for you to perform the job that you are applying for to the best of your ability please list below:

  • Section 2 (Education):


  • High School:


  • High School Name:

  • Address:

  • Years completed:





  • Received Diploma?:



  • Please describe any specialized training, skills learned or extra-curricular activities:

  • Undergraduate:


  • College/University:

  • Address:

  • Years Completed:





  • Received Degree?:



  • Course(s) of Study:

  • Please describe any specialized training, skills learned or extra-curricular activities:

  • Graduate/Professional:


  • College/University:

  • Address:

  • Years Completed:





  • Received Degree?:



  • Major course of study:

  • Please describe any specialized training, skills learned or extra-curricular activities:

  • List membership in professional, civic, social or honorary organizations. (You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, handicap or other protected status):

  • Please list any specialized skills or qualifications you may have acquired which pertain to the position for which you are applying:

  • Section 3 (Applicant Background Investigation):


  • West Virginia Law and the Department of Health and Human Resources requires child care agencies to conduct a thorough background investigation on all prospective employees. Your signature at the end of this application signifies your authorization for Youth Services System, Inc. to investigate your background pertaining to any past criminal record, social service history, Department of Motor Vehicles records, personal/character references, professional references, and employment references.

  • A. REFERENCES:


  • List three references(not relatives or friends) for example; professional, clergy, work supervisor, teachers, professors, and describe how you know them:

  • Name:

  • Address:

  • Phone:
    Contact Preference:
    E-mail:

  • Relationship to Reference:

  • Name:

  • Address:

  • Phone:
    Contact Preference:
    E-mail:

  • Relationship to Reference:

  • Name:

  • Address:

  • Phone:
    Contact Preference:
    E-mail:

  • Relationship to Reference:

  • B. EMPLOYMENT EXPERIENCE:


  • Start with PRESENT OR MOST RECENT job. Include military service assignments and volunteer activities. You may exclude any organizations which indicate race, color, religion, gender, national origin, disability or other protected status:

  • 1:


  • Employer:

  • Address:

  • Phone:
    Contact Preference:
    E-mail:

  • Position:

  • Supervisor:

  • Employed Start Date:
    Employed End Date:

  • Starting Wage:

  • Ending Wage:

  • Reason for leaving:

  • 2:


  • Employer:

  • Address:

  • Phone:
    Contact Preference:
    E-mail:

  • Position:

  • Supervisor:

  • Employed Start Date:
    Employed End Date:

  • Starting Wage:

  • Ending Wage:

  • Reason for leaving:

  • 3:


  • Name:

  • Address:

  • Phone:
    Contact Preference:
    E-mail:

  • Position:

  • Supervisor:

  • Employed Start Date:
    Employed End Date:

  • Starting Wage:

  • Ending Wage:

  • Reason for leaving:

  • C. RESIDENCE:


  • Last three home addresses. Begin with most recent previous address.

  • Address:
    City:
    County:
    State:
    ZIP:

  • Amount of time spent at this residence:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Amount of time spent at this residence:

  • Address:
    City:
    County:
    State:
    ZIP:

  • Amount of time spent at this residence:

  • Have you ever lived outside of West Virginia:



  • D. CRIMINAL CONVICTIONS:


  • Have you ever been convicted of a felony/misdemeanor crime?:

  • Are you currently on probation or parole? :

  • If yes to either question, please provide the following information:


  • Conviction Date (MM/DD/YYYY):

  • Charge:

  • Category:



  • State/County of Charge:

  • Disposition:

  • E. DRIVING RECORD:


  • Driver's License #:

  • State Issued:

  • Exp. Date (MM/DD/YYYY):

  • Do you currently have a valid Driver's License?:



  • Have you ever been ticketed for a moving violation?:



  • If Yes, Explain:

  • Do you currently have any "points" on your license?:



  • If Yes, Explain:

  • Have you ever been convicted of Driving while Intoxicated?:



  • If Yes, Explain:

  • Has your Driver's License ever been suspended or revoked?:



  • If Yes, Explain:

  • Section 4 (Applicants Statement):


  • During the application process and at any time during the tenure of my employment
    with Youth Services System, Inc., I hereby authorize and grant permission to Youth
    Services Systems, Inc. to conduct a thorough background investigation including
    criminal records, social service records, Motor Vehicles records, character
    references, professional references, employment references and other sources that
    may be deemed appropriate and to make inquires about any information that I have
    given in this application.

    In the event I, the applicant, have requested no contact with my current employer
    I understand that the current employer will be contacted once I have accepted a
    conditional offer of employment. The offer of employment is contingent on a
    satisfactory reference from the current employer.

    A photocopy or facsimile copy of this authorization shall serve as an original.

    I agree to submit to a criminal background investigation as a condition of
    employment. I attest to the fact that I have never been convicted of murder,
    abduction, kidnapping sexual offenses, contributing to the delinquency of a minor
    child, or any other violent crime against a person. Further, I attest to the fact
    that I have been convicted of no other crimes, except as listed on page four. I am
    not currently on parole or probation, nor charged with or under indictment for any
    criminal offense, except as listed in page four.I understand that this statement may
    be reviewed by any local, state, and/or federal law enforcement or judicial officials
    as may be deemed appropriate.

    I understand that an offer of employment or continued employment is contingent upon a
    clear criminal background, child protective services clearance, clear driving record,
    current valid drivers license, verification of credentials, clear health screen
    and other clearances.

    I certify that all 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 for arriving at an employment decision.

    I understand and agree that, if hired, any employment relationship is one of
    “employment at will”and is not for a definite period and may, regardless of the date
    of payment of my wages and salary, be terminated at any time, without any prior
    notice, with or without cause.

  • ELECTRONIC SIGNATURE:



  • By submitting your name in the text field below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this application.

  • Electronic Signature (Full Name):

  • Date:

  • AUTHORIZATION FORM FOR BACKGROUND INVESTIGATION:


  • During the application process and at any time during the tenure of my
    employment with Youth Services System, Inc., I hereb authorize First
    Advantage,ScreenNow, or ADP (Automated Data Processing) on behalf of
    Youth Services System, Inc. to procure a investigative consumer report
    which I understand may include information regarding my character,
    general reputation, personal characteristics, or mode of living. This
    report may be compiled with information from courts record
    repositories, past or present employers, departments of motor vehicles,
    and educational institutions, governmental occupational licensing or
    registration entities, credit bureaus, business or personal references,
    and any other source required to verify information that I have
    voluntarily supplied. I underatand that I may request a complete and
    accurate disclosure of the nature and scope of the background
    verification to the extent such investigation includes information
    bearing on my character, general reputation, personal characteristics
    or mode of living.

  • Electronic Signature (Full Name):

  • Date:
Enter This Verification Number (Required)