Application For Employment

Step 1 of 7

14%

PERSONAL INFORMATION

Date

MM slash DD slash YYYY

Name(Required)

First Middle Last

SOCIAL SECURITY NUMBER

PERMANENT ADDRESS

Street Address Line 2 City State ZIP

PHONE NO.(Required)

ARE YOU 18 YEARS OR OLDER?(Required)

Yes

ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?(Required)

Yes

EMPLOYMENT DESIRED

POSITION

DATE YOU CAN START

MM slash DD slash YYYY

SALARY DESIRED

ARE YOU EMPLOYED NOW?(Required)

IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?

EVER APPLIED TO THIS COMPANY BEFORE?

WHERE?

WHEN?

REFERRED BY

EDUCATION

Grammar School

Name and Location of School(Required)

Did You Graduate?

Yes

No. of Years Attended

Subjects Studied

High School

Name and Location of School

Did You Graduate?(Required)

Yes

No. of Years Attended

Subjects Studied

Trade, Business or Correspondence School

Name and Location of School

Did You Graduate?(Required)

Yes

No. of Years Attended

Subjects Studied

College

Name and Location of School

Did You Graduate?(Required)

Yes

No. of Years Attended

Subjects Studied

GENERAL

SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK

SPECIAL SKILLS

ACTIVITIES: (CIVIC, ATHLETIC, ETC.) Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color or nation of origin of its members.

U.S. MILITARY OR NAVAL SERVICE

RANK

PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES

FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST.)

Date (Month and Year)

MM slash DD slash YYYY

Name and Address of Employer

Salary

Position

Reason for Leaving(Required)

From

MM slash DD slash YYYY

Date (Month and Year)

MM slash DD slash YYYY

Name and Address of Employer(Required)

Salary

Position

Reason for Leaving

From

MM slash DD slash YYYY

Date (Month and Year)

MM slash DD slash YYYY

Name and Address of Employer(Required)

Salary

Position

From

MM slash DD slash YYYY

WHICH OF THESE JOBS DID YOU LIKE BEST?

WHAT DID YOU LIKE MOST ABOUT THIS JOB?

REFERENCES: Give the names of three persons not related to you, whom you have known at least one year.

Name(Required)

Address

Business

Years Acquainted

Name(Required)

Address

Business

Years Acquainted

Name(Required)

Address

Business

Years Acquainted

THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTS. (Fill in name of state.) It is unlawful in the State of __________________ to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Signature of Applicant(Required)

IN CASE OF EMERGENCY NOTIFY

Name(Required)

Address

Phone No.(Required)

If any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its President, and then only when in writing and signed by the President, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

Date

MM slash DD slash YYYY

Signature(Required)

DO NOT WRITE BELOW THIS LINE

INTERVIEWED BY

Date

MM slash DD slash YYYY

REMARKS

NEATNESS

ABILITY

HIRED

Yes

POSITION

DEPT.

SALARY/WAGE

DATE REPORTING TO WORK

MM slash DD slash YYYY

APPROVED

EMPLOYMENT MANAGER

DEPT. HEAD

GENERAL MANAGER

This form has been designed to strictly comply with State and Federal fair employment practice laws prohibiting employment discrimination. This Application for Employment Form is sold for general use throughout the United States. TOPS assumes no responsibility for the inclusion in said form of any questions which, when asked by the Employer of the Job Applicant, may violate State and/or Federal Law.

Florida Department of Law Enforcement

NOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL RECORD RESULTS WILL BECOME PART OF THE CARE PROVIDER BACKGROUND SCREENING CLEARINGHOUSE

NOTICE OF:

SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES,
RETENTION OF FINGERPRINTS,
PRIVACY POLICY, AND
RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD

This notice is to inform you that when you submit a set of fingerprints to the Florida Department of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history records that may pertain to you, the results of that search will be returned to the Care Provider Background Screening Clearinghouse. By submitting fingerprints, you are authorizing the dissemination of any state and national criminal history record that may pertain to you to the Specified Agency or Agencies from which you are seeking approval to be employed, licensed, work under contract, or to serve as a volunteer, pursuant to the National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. "Specified agency" means the Department of Health, the Department of Children and Families Services, the Division of Vocational Rehabilitation within the Department of Education, the Agency for Health Care Administration, the Department of Elder Affairs, the Department of Juvenile Justice, and the Agency for Persons with Disabilities when these agencies are conducting state and national criminal history background screening on persons who provide care for children or persons who are elderly or disabled. The fingerprints submitted will be retained by FDLE and the Clearinghouse will be notified if FDLE receives Florida arrest information on you.

Your Social Security Number (SSN) is needed to keep records accurate because other people may have the same name and birth date. Disclosure of your SSN is imperative for the performance of the Clearinghouse agencies' duties in distinguishing your identity from that of other persons whose identification information may be the same as or similar to yours.

Licensing and employing agencies are allowed to release a copy of the state and national criminal record information to a person who requests a copy of his or her own record if the identification of the record was based on submission of the person's fingerprints. Therefore, if you wish to review your record, you may request that the agency that is screening the record provide you with a copy. After you have reviewed the history record, if you believe it is incomplete or inaccurate, you may conduct a personal review as provided in s. 943.056, F.S., and Rule 11C-8.001, F.A.C. If national information is believed to be in error, the FBI should be contacted at 304-625-2000. You can receive any national criminal history record that may pertain to you directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the right to obtain a prompt determination as to the validity of your challenge before a final decision is made about your status as an employee, volunteer, contractor, or subcontractor.

Until the criminal history background check is completed, you may be denied unsupervised access to children, the elderly, or persons with disabilities.

The FBI's Privacy Statement follows on a separate page and contains additional information.

Care Provider Background Screening Clearinghouse

Background Screening Request Form

You have applied for a position with a health care and/or service provider regulated by a specified agency in the Care Provider Background Screening Clearinghouse (Clearinghouse) that requires a fingerprint-based background check. As a health care and/or service provider regulated by a specified agency in the Clearinghouse we may conduct a search for an existing background screening result or submit a new background screening request through the Clearinghouse results website on your behalf.

In order to complete the search and/or background screening request we must collect the following information. This information is required by the Clearinghouse, the Florida Department of Law Enforcement, and the Federal Bureau of Investigation.

Please provide the following information:

Applicant Information

Name(Required)

First Name Middle Name Last Name

Aliases

SSN(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Place of Birth(Required)

Demographics

Sex(Required)

Race(Required)

Hair Color(Required)

Eye Color(Required)

Height(Required)

Weight(Required)

Contact Information

Address(Required)

Address Line 1 Address Line 2 City State Zip County

Prior State(Required)

Phone

US Department of Justice

Federal Bureau of Investigation

Criminal Justice Information Services Division

FBI PRIVACY ACT STATEMENT

Authority:

The FBI's acquisition, preservation, and exchange of information requested by this form is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include numerous Federal statutes, hundreds of State statutes pursuant to Pub.L. 92-544, Presidential executive orders, regulations and/or orders of the Attorney General of the United States, or other authorized authorities. Examples include, but are not limited to: 5 U.S.C. 9101; Pub.L. 94-29; Pub.L. 101-604; and Executive Orders 10450 and 12968. Providing the requested information is voluntary; however, failure to furnish the information may affect timely completion or approval of your application.

Social Security Account Number (SSAN):

Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

Principal Purpose:

Certain determinations, such as employment, security, licensing, and adoption, may be predicated on fingerprint-based checks. Your fingerprints and other information contained on (and along with) this form may be submitted to the requesting agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing the submitted information to available records in order to identify other information that may be pertinent to the application. During the processing of this application, and for as long hereafter as may be relevant to the activity for which this application is being submitted, the FBI may disclose any potentially pertinent information to the requesting agency and/or to the agency conducting the investigation. The FBI may also retain the submitted information in the FBI's permanent collection of fingerprints and related information, where it will be subject to comparisons against other submissions received by the FBI. Depending on the nature of your application, the requesting agency and/or the agency conducting the application investigation may also retain the fingerprints and other submitted information for other authorized purposes of such agency(ies).

Routine Uses:

The fingerprints and information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b)) and all applicable routine uses as may be published at any time in the Federal Register, including the routine uses for the FBI Fingerprint Identification Records System (Justice/FBI-009) and the FBI's Blanket Routine Uses (Justice/FBI-BRU). Routine uses include, but are not limited to, disclosures to: appropriate governmental authorities responsible for civil or criminal law enforcement, counterintelligence, national security or public safety matters to which the information may be relevant; to State and local governmental agencies and nongovernmental entities for application processing as authorized by Federal and State legislation, executive order, or regulation, including employment, security, licensing, and adoption checks; and as otherwise authorized by law, treaty, executive order, regulation, or other lawful authority. If other agencies are involved in processing this application, they may have additional routine uses.

Additional Information:

The requesting agency and/or the agency conducting the application investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any system(s) of records in which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).

PRIVACY POLICY ACKNOWLEDGEMENT FORM

I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse.

I understand and agree that I will read and comply with the guidelines contained in the privacy policies.

Employee/Contractor Name (Printed)

Employee/Contractor Signature(Required)

Date

MM slash DD slash YYYY

Application For Employment

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

Grammar School

High School

Trade, Business or Correspondence School

College

GENERAL

FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST ONE FIRST.)

REFERENCES: Give the names of three persons not related to you, whom you have known at least one year.

IN CASE OF EMERGENCY NOTIFY

DO NOT WRITE BELOW THIS LINE

Florida Department of Law Enforcement

Care Provider Background Screening Clearinghouse

Background Screening Request Form

Applicant Information

Demographics

Contact Information

FBI PRIVACY ACT STATEMENT

Authority:

Social Security Account Number (SSAN):

Principal Purpose:

Routine Uses:

Additional Information:

PRIVACY POLICY ACKNOWLEDGEMENT FORM

Schedule Appointment