Employment Application

We are an equal opportunity employer, dedicated to a policy of non-discrimination on any basis including race, color, religion, creed, national origin, age, veteran status, marital status, citizenship, disability, or any other characteristics protected under the law.

Please complete and submit this application form on-line. Your IP address has been automatically recorded.
Position Applied For: 
Desired Salary: 
Application Date: 
How did you learn about us: 
Last Name: 
First Name: 
Middle Name: 
Address: 
 
City: 
State: 
Zip Code: 
Social Security Number: 
Date of Birth: 
Phone: 
Cellular: 
E-mail: 

Have you ever filed an
application with us before?		 Yes  No
If yes,
please specify the date: 

Are you currently employed?  Yes  No
If yes, may we contact
your current employer? 		 Yes  No

Do you have legal right to
work in the United States? 		 Yes  No
Proof of citizenship or immigration status will be required upon employment.

On what date would you
be available for work: 
Are you available to work:
 Full Time    Part Time    Shift Work    Temporary  

Please share with us, details regarding
the highest level of education that
you have, or your degree
if you have one: 
Are you currently on "lay-off"
status and subject to recall? 		 Yes  No
Can you travel if
the job requires it? 		 Yes  No

Have you ever been convicted
of a felony or any other crime*? 		 Yes  No
If yes, please explain: 
Are you currently or
have you ever been excluded,
debarred, suspended or
otherwise ineligible to
participate in the Federal
health care programs or
in Federal procurement
or nonprocurement programs? 		 Yes  No

Please indicate any foreign language(s) you can speak, read or write fluently: 


Employment Experience

Please provide the following information concerning each of your employers, starting with your present or most recent position. (You may include any verified work performed as a volunteer).

Name of Employer (1): 
Telephone Number: 
Address: 
 
City: 
State: 
Zip Code: 
Supervisor's Name: 
Supervisor's Title: 
Date Employed From:
 Date Employed To:
Starting Rate of Pay:
 Final Rate of Pay:
Title: 
Reason for leaving: 
Describe the work performed: 


Name of Employer (2): 
Telephone Number: 
Address: 
 
City: 
State: 
Zip Code: 
Supervisor's Name: 
Supervisor's Title: 
Date Employed From:
 Date Employed To:
Starting Rate of Pay:
 Final Rate of Pay:
Title: 
Reason for leaving: 
Describe the work performed: 



References
Name: 
Phone: 
E-mail: 
Organization: 
Relationship: 
Address: 
 
City: 
State: 
Zip Code: 


Name: 
Phone: 
E-mail: 
Organization: 
Relationship: 
Address: 
 
City: 
State: 
Zip Code: 



Applicants will receive consideration for positions, without regard to age, ancestry, color, genetic information, learning disability, marital status, past or present history of mental disability, intellectual disability, national origin, physical disability, race, religious creed, sex, including pregnancy, sexual harassment or transgender status, or sexual orientation, or any other legally protected class.

I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that failure to reveal any prior employer or giving false or misleading information by me on any part of the Application of Employment can be grounds for termination from the company.

I understand that if I am hired, my status will be that of an employee at will, with no contractual right, express or implied, to remain employed. Employees may be terminated, with or without cause or notice, at any time at the option of my employer or me.

All employment offers are made contingent upon satisfactory proof of legal authorization to work in the United States according to the law. I understand that failure to provide satisfactory proof of identity and authorization to work in the United States will disqualify me from employment.

Ascension Habilitative Support Services, LLC Provides Member-Focused Services to all Program Participants.

To that end, we involve program participants and their family/conservators in making hiring decisions whenever possible. During the interview process, I understand that I may be asked to meet with the program participant and their family or conservator. During this process, I may be privy to confidential information which I understand I am prohibited from disclosing.

As a member-focused agency, I understand that employment with any program participant is contingent upon the satisfaction of the program participant and his/her team, including family members and conservators as well as upon the ability of the employee to meet agency standards. When a program participant or their team members believe that a staff change is in the best interest of the program participant, I understand that this staff change may result in loss of employment to an employee.

I agree that when I complete the "signature" fields below in this electronic document/form and submit it, I understand that it is the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Signed: 
Date: 


Consent to Drug/Alcohol Testing and Release of Results

I do hereby consent to undergo a drug/alcohol test, as required by Ascension Habilitative Support Services (employer). Furthermore, I authorize the hospital, clinic, and/or testing facility to release to Ascension Habiltative Support Services (employer) the results of such test and I release the hospital, clinic, and/or testing facility, its doctors, and medical personnel from liability from any release or use of this information.

Signed: 
Date: 


Candidate Driving Information Verification

Name: 
Driver's License #: 
State: 
License Expiration Date: 
Valid Vehicle Registration:  Yes  No
Registration Expiration Date: 
Insurance Company: 
Coverage Start Date:
 Coverage End Date:





*Ascension LLC will not unlawfully deny employment to applicants who have criminal records and will conform to the requirements of CGS 46a-80. Special Note: you are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to CGS 46b-146, 54-76o, or 54-142a. If your criminal records have been erased pursuant to one of these statutes, you may swear under oath that you have never been arrested. Criminal records may be erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs (CGS 46b-146), an adjunctication as a youthful offender (CGS 54-76o) a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received absolute pardon (CGS 54-142a)