Apply Here

Date of Birth *

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Driver License Expiration *

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Current Address *

Address 1

Address 2

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Former Address

Address 1

Address 2

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Care Provider

Cook

Clerical

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Date you can Start

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Computer Skill Level

Email Communicating

Internet/Web Browsing

Word Processing

Spreadsheet

Database

No skill but willing to learn

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Date Ended

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Name *

First Name

Last Name

Phone Number

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Name *

First Name

Last Name

Phone

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Name *

First Name

Last Name

Phone

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I hereby authorize and request any and all of my former employers and any other person, firm or corporation to furnish any and all information concerning my credit-worthiness and personal background and I hereby release each such employer or other person, firm or corporation from any and all liability by reason of furnishing the requested information. I understand that in connection with this application, a consumer report and/or an investigative consumer report may be requested whereby information is obtained through personal interviews with my neighbors, friends, associates or with others with whom I authorize the procurement of any such report. I understand that ,upon my request, I have the right to know if any such report was requested and, if so, the name and address of the consumer reporting agency that furnished such report and in the case of a consumer investigative report, that I may inspect and receive a copy of such report by contacting such agency. I also understand that I have the right to receive a complete and accurate disclosure of the nature and scope of the information requested if I request such disclosure within a reasonable period of time. I, the undersigned applicant, certify and affirm that to the best of my knowledge and belief. I ("have" or "have not" (as applicable) had a case of abuse, neglect, mistreatment or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation, I further release and authorize Scott Appalachian Industries, Inc. the Tennessee Department of Intellectual and Developmental Disabilities and the Division of TennCare to have full and complete access to any and all current or prior personal or investigative records from any party, person, business, entity, or agency,whether governmental or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment or exploitation and to consider this information as may be deemed appropriate. This authorization extends to providing any applicable information in personal or investigative reports concerning my employment with this employer to my future employers who may be providers of DIDD services. I understand that if employed: 1)any misrepresentation or omission of facts requested in this application is cause for dismissal: and 2)my employment is for no definite period and I may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice. REV: 111220gq *

I Agree