Youth Services System, Inc. does not discriminate against any person based upon a protected group status, including but not limited to race, color, religion, gender (including pregnancy), sexual orientation, gender identity or expression, national origin, ancestry, citizenship status, age, marital status, genetic information, physical or mental disability, medical condition, or veteran status, and any other categories protected by federal, state or local laws, ordinances, or regulations.

Section I - Personal Data:

Position(s) Applied For:

First Name:

MI:

Last Name:

Address:		City:
County:	State: NoneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming	ZIP:

Phone:	Contact Preference: No Preference Phone Email
E-mail:

Are you currently working:
Yes
No

Date you are available to start work:

Have you worked for YSS previously:
Yes
No

What hourly rate or salary are you seeking:

Do you have a valid driver's license:
Yes
No

Can you travel if your position requires it:
Yes
No

Are you at least 18 years of age? Our licensing regulations requires that you be at least 20 years of age to work in our residential facilities. If applicable, do you meet this requirement? :
Yes
No

How did you hear about this opportunity:
YSS Website
Indeed
Facebook
Other Website
WorkforceWV
Radio, Television
Employee Referral
Other

Do you have relatives that work at YSS:
Yes
No

Are you eligible to work for any employer in the United States:
Yes
No

Are you available:
Full-Time
Part-Time
Seasonal
Temporary

Are you available to work overtime:
Always
Sometimes
Rarely
Never

What shift(s) can you work:
Days
Afternoons
Midnights
Weekends
Straight Shift Only
Variable Shifts

Section II - Education:

High School:

High School Name:

Address:

Phone:

Diploma:
Yes
No

If no, years completed:
9
10
11
12
GED

Special Skills, Training:

Trade / Vocational School:

School Name:

School Address:

Did you graduate:
Yes
No

If no, years completed:

Degree/Certificate:

College / University:

College / University Name:

Address:

Did you graduate:
Yes
No

If no, years completed:
1
2
3
4

Degree / Major - Minor:

Section III - Employment:

Current Employer Name:

Current Employer Address & Telehpone Number:

May we contact your current employer:
Yes
No

Dates of Employment Start Date:

Dates of Employment End Date:

Position:

Section V - Eligibility:

WV State Code and WV Department of Health and Human Resources requires licensed, certified, and registered child care agencies to conduct a thorough background on all prospective employees. As a part of such background, we will conduct a personnel criminal records if you are selected for hire. Please review information regarding convictions, which may affect your ability to work for Youth Services Systems, Inc.

All applicants shall not be approved, employed, utilized nor considered for a waiver if convicted of:

(a) Abductions;
(b) Any violent felony crime including, but not limited to rape, sexual assault, homicide, malicious wounding, unlawful wounding, felonious domestic assault or battery;
(c) Child/adult abuse or neglect;
(d) Crimes which involve the exploitation of a child or an incapacitated adult;
(e) Misdemeanor domestic battery or domestic assault;
(f) Felony arson;
(g) Felony or misdemeanor crime against a child or incapacitated adult which causes harm;
(h) Felony drug related offenses within the last ten (10) years;
(i) Felony DUI within the last ten (10) years;
(j) Hate crimes;
(k) Kidnapping;
(l) Murder/homicide;
(m) Neglect or abuse by a caregiver;
(n) Pornography crimes involving children or incapacitated adults including but not limited to, use of minors in filming sexually explicit conduct, distribution and exhibition of materials depicting minors in sexually explicit conduct or sending, distributing, exhibiting, possessing, displaying or transporting material by a parent, guardian or custodian, depicting a child engaged in sexually explicit conduct;
(o) Purchase or sale of a child; or
(p) Sexual offenses including but not limited to incest, sexual abuse, or indecent exposure.

Additionally:

(a) the applicant shall not be approved, employed, utilized or considered for a waiver if on parole or probation for a felony conviction.
(b) the applicant shall not be approved, employed, nor utilized if convicted of a felony not listed above unless a waiver is requested and approved.
(c) an applicant shall not be approved, employed, nor utilized if convicted of two or more misdemeanors unless a waiver is requested and approved.
(d) An applicant shall not be approved, employed, nor utilized if he/she fails to report convictions to YSS or Department of Health and Human Resources on the Criminal Background Check, unless a waiver is requested and approved.

Nolo Contendere Pleas


(a) If an applicant s criminal background check indicates a nolo contendere plea for a crime against a child or incapacitated adult, the applicant shall not be approved, employed, utilized nor considered for a waiver.
(b) If an applicant s criminal background check indicates a nolo contendere plea that is not against a child or incapacitated adult, the applicant s plea will be evaluated by the Regional or State Office CIB committee for approval or denial. In reviewing such, the committee will evaluate the crime, plea, and circumstances surrounding the crime in relation to a person s character.
(c) The nolo contendere plea cannot be considered a conviction.

Based upon the above, I have read the WV State licensing regulations, and I am:
eligible for employment at YSS.
not eligible for employment at YSS; however, there are extenuating circumstances, and I may qualify for a waiver.
eligible for employment at YSS at this time.
need to speak with someone before proceeding.

Section VI - Acknowledgement & Affirmation:

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Youth Services System, Inc. ( YSS ) to hire me. If I am hired, I understand that either YSS or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of YSS has the authority to make any assurance to the contrary.

Based upon WV State law and WV Health and Human Resources regulations, I understand that Youth Services Systems, Inc. will conduct a thorough background investigation including criminal, social services, motor vehicles records; character, professional, and employment references; consumer or financial background; and any other sources deemed necessary to make inquiries about my eligibility for employment and to confirm any information I have provided. I understand that by signing this application, I am acknowledging YSS may monitor my background and periodically confirm my eligibility for employement at any time during my tenure.

I attest that I have never been convicted of murder, abductions, kidnapping, sexual offenses, contributing to the delinquency of a minor, or any other violent crimes against a child or adult. Further, I attest that I have not been convicted of any crimes, and am not currently on probation or parole or charged with or under indictment for any criminal offense, except as outlined in this application and any supplemental documents attached hereto. 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 to assess my fitness for employment. I further understand that, if I am hired, I have an obligation to report any criminal arrests or charges to Youth Services System, Inc. immediately.

I understand that any offer of and continued employment by YSS is conditional upon receiving a clear criminal background, child protective services clearance, a clean driving record (where applicable), verification of credentials, physical examination, and any other clearance required in accordance with Federal, State and Local Laws and/or WV Health and Human Resources. Furthermore, if I have requested that my current employer not be contacted, above, I understand that any offer of employment is conditional upon confirmation from my current employer about my dates of employment and position. A photocopy, facsimile, or electronic copy of this authorization has the same enforcement as the original.

I attest with my signature below that all the facts and information I have provided to Youth Services System, Inc. on this application, and any supplements to, are true and complete. No requested information has been concealed. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.


My electronic signature herein shall have the same enforcement and authority as my handwritten signature.

Signature:

Date:

Section VII - Voluntary Self-Identification:

Youth Services System, Inc. ( YSS ) is a government contractor and employer subject to federal laws, the agency is required to provide certain information to the U.S. government. In order to comply with federal/state equal opportunity recordkeeping, reporting and other legal requirements, we would appreciate you voluntarily answering the questions below. You are not required to answer them, and refusal to provide the information will not affect the consideration of your application, nor will it result in adverse treatment. Any information you provide on this form will be kept in a confidential file separate from your application for employment.

YSS does not discriminate against any person based upon any protected group status, including but not limited to, race, color, religion, gender (including pregnancy), sexual orientation, gender identity and expression, national origin, ancestry, citizenship status, age, marital status, genetic information, physical or mental disability, medical condition, or veteran status, and all other categories protected by federal, state, or local laws, ordinances, or regulations.

Gender:
Male
Female

Race / Ethnicity:
American Indian/Alaskan Native (A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.)
Asian (A person have origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Phillipine Islands, Thailand, and Vietnam.)
Black/Afrian American (A person having origins in any of the black racial groups of Africa.)
Native Hawaiian/Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
Hispanic/Latino (A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Two or More Races (A person who primarily identifies with two or more of the above race/ethnicity categories.)
White/Caucasion (A person having origins in any of the original peoples of Europe, the Middle East or North Africa.)
Decline to Answer (If you choose not to self-identify your race/ethnicity at this time, the federal government requires YSS to determine this information by visual survey or other available information.)

Voluntary Self-Identification of Disability

Form CC-305 OMB Control Number 1250-0005
Expires 1/31/2020

Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities1. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

*Blindness
*Autism
*Bipolar Disorder
*Post-Traumatic Stress Disorder (PTSD)
*Deafness
*Cerebal Palsy
*Major Depression
*Obsessive Compulsive Disorder
*Cancer
*HIV/AIDS
*Multiple sclerosis (MS) *Impairments requiring the use of a wheelchair
*Diabetes
*Schizophrenia
*Missing limbs or partial missing limbs
*Intellectual Disability (previously called mental retardation)
*Epilepsy
*Muscular Dystrophy

Please check one of the boxes below:
Yes, I have a disability (or previously had a disability)
No, I don't have a disability answer
No, I don't have a disability

Signature:

Date:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.



_______________________________
1Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.