Join our team – Welcome to Impact's TLC

Personal Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Position Applying for: *

Support Staff
Van Driver/Floater

Choose all that apply.

Employment

Current Place of Employment: *

Title *

Length of employment: *

Current Salary/Hourly Rate: *

Date Available to Start: *

Date of last fingerprint/background check:

Education

High School:

Graduation Date:

College/University:

Graduation/Expected Graduation Date:

Degree/Major/Minor:

Please upload current resume: *

Click or drag a file to this area to upload.

References:

Two professional references and one personal reference. Please do not include relatives.

Professional References

Name: *

First

Last

Phone: *

Professional Association: *

Name: *

First

Last

Phone: *

Professional Association: *

Personal Reference

Name *

First

Last

Phone: *

Personal Association: *

General Background Information

You must give complete answers to all questions. If you answer "Yes" to any question, you must list all offenses, and for each conviction provide date of conviction and disposition, regardless of the date or location of occurrence. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. Your answers will be verified with appropriate police records. Criminal Offense includes felonies, misdemeanors, summary offenses and convictions resulting from a plea of "nolo contendere" (no contest). Conviction is an adjudication of guilt and includes determinations before a court, a district justice or a magistrate, which results in a fine, sentence or probation. You may omit: minor traffic violations, offenses committed before your 18th birthday which were adjudicated in juvenile court or under a Youth Offender Law, and any convictions which have been expunged by a court or for which you successfully completed an Accelerated Rehabilitative Disposition program. Professional disciplined means the annulment, revocation or suspension of your teaching certification or having received a letter of reprimand from an agency, board or commission of state government, such as the Professional Standards and Practices Commission.

Have you ever been convicted of a criminal offense? *

Yes
No

Are you currently under charges for a criminal offense? *

Yes
No

Have you ever forfeited bond/collateral in connection with a criminal offense? *

Yes
No

Have you ever been fired from any job for any reason in the last ten years? *

Yes
No

Have you ever quit a job after being notified that you would be fired within the last ten years? *

Yes
No

Have you ever been professionally disciplined in any state? *

Yes
No

Are you subject to any visa/immigration status which would prevent lawful employment? *

Yes
No

Please explain any checked items above:

Additional Information:

Please include any additional information/experience you would like us to take into consideration.