Contact Information

Work Preferences

Please check all that describe your work preference:


Applicant Information

Are you 18 years or older?

Can you legally work in the United States?

Have you worked for CCLS before?

Are you related to anyone employed by CCLS?

Do you have a valid drivers license?

Do you have access to an insured reliable vehicle?


Employment History & References

Have your employment or educational records ever been listed under another name?

Employment Record

May we contact for a reference?

Employment Record

May we contact for a reference?

Employment Record

May we contact for a reference?

Have you ever been fired, discharged, or asked to resign from a position?

Other References

List individual(s) not related to you or employed by CCLS that you have known for at least 2 years. (Example: professor, volunteer, clergy, etc.)

Reference Record

Reference Record

Reference Record


Education / Certifications

Do you have a high school diploma or GED?

Education Record

Graduated?

Education Record

Graduated?

Education Record

Graduated?


Certification Record

Status?

Certification Record

Status?

Certification Record

License / Certification

Status?


Please read and accept the following agreement.

CERTIFICATE OF APPLICANT: I authorize Creative Community Living Services, Inc. (CCLS) to make any inquiry of or receive information from any person or organization regarding my suitability for employment; and do hereby give permission to these persons or organizations to provide such information. Such inquires may include and not be limited by enumeration to the quality and quantity of my work, work history, and record, character, qualification, records of convictions and medical records. For and in consideration of the release of such information, I hereby forever waive, release and covenant not to sue any person or organization including CCLS, its agents and employees for the result of providing, obtaining, or acting upon such information. I give this waiver, release and covenant not to sue understanding that the information obtained may be such as to disqualify me for employment. I understand that such information is sought with confidentiality, and I will not request copies of such information. I also certify that all statements made on this application are true and complete, accurate and not misleading to the best of my knowledge. I understand that false statements, incomplete statements, omissions, or misrepresentations may subject me to disqualification or dismissal. A copy of this authorization shall be as effective as the original.

My typed name below shall have the same force and effect as my written signature.