Application for Employment

Name*

FirstLast

Address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Phone*

Email

Please provide any additional information on how to best contact you:

How did you hear about Alaska Children's Services?

Current or former ACS Staff

Name

Online posting

Site Name or URL

Anchorage Daily News
University/College Referral
University/College Advertisement
State Employment Service

Other

Please Specify

Position Sought

1. Position*

Psychiatric Treatment Counselor (PTC)
Activity Therapist
Other

If other, please specify:

2. Preferred Hours*

Full-time
Part-time
On-call/Relief
Other

If part time or other, please specify hours:

3. What hours and/or days are you NOT available to work?*

4. When could you begin employment?*

Have you ever worked for Alaska Children's Services before?*

If yes, in what position?

Are you related to anyone currently on the Board of Directors of Alaska Children's Services?*

If yes, to whom?

Do you have a current Alaska driver's license?*

If no, will you be able to obtain one?

Can you provide documentation to verify your eligibility to work in the United States?*

If applying to work directly with clients, are you at least 21 years of age as required by state licensing regulations?*

Have you had any traffic or motor vehicle violations in any state over the past three years?*

If yes, please explain:

Have you ever been convicted of a misdemeanor or felony or are you currently under indictment for a charge?*

If yes, please explain:

Note: The Office of Children's Services licensing regulations prohibit the hire of individuals under indictment, charged by information or complaint, or convicted for actions delineated in licensing regulation 7AAC50.210 and its corresponding state statutes.

Educational History

High School name, city and state*

Course of study, if applicable

Last year completed*

Did you graduate?*

Did you receive a diploma or a GED certificate?

College/University name, city and state

Course of study

Credit hours earned

Did you graduate

Degree achieved

College/University name, city and state

Course of study

Credit hours earned

Did you graduate

Degree achieved

Employment History

Cover the past 10 years, starting with your most recent position. Include relevant internships and volunteer experiences.

Employer*

Supervisor*

Address*

Phone*

Dates of employment from/to*

Job title*

Salary*

Average hours worked per week*

Reason for leaving/wanting to leave*

Briefly describe responsibilities*

May we contact this employer?*

Employer

Supervisor

Address

Phone

Dates of employment from/to

Job title

Salary

Average hours worked per week

Reason for leaving/wanting to leave

Brief description of responsibilities

May we contact this employer?

Employer

Supervisor

Address

Phone

Dates of employment from/to

Job title

Salary

Average hours worked per week

Reason for leaving/wanting to leave

Brief description of responsibilities

May we contact this employer

Employer

Supervisor

Address

Phone

Dates of employment from/to

Job title

Salary

Average hours worked per week

Reason for leaving/wanting to leave

Brief description of responsibilities

May we contact this employer?

Personal references

List two references other than relatives or employers, who have knowledge of your character.

Name*

Mailing address*

Phone*

Email

Name*

Mailing address*

Phone*

Email

I certify that the information supplied by me is true and correct to the best of my knowledge and that I have not knowingly withheld or falsified any fact or circumstance. I understand that, if employed, false statements on this application will be considered sufficient grounds for immediate dismissal. I understand that my initial and continued employment, if such an agreement is reached, is subject to: 1. Obtaining and renewing any and all permits, licenses, or registrations to practice, serve or work as may be required. 2. Verification of my identity and eligibility to work in the United States 3. Verification that I am not on the Office of Inspector General's exclusionary list for participation in federal health care programs. 4. Verification that I am free of active tuberculosis. 5. Certification through a post-offer physical examination of my ability to perform certain functions of the job (if required for the position). 6. Receipt of a satisfactory criminal background check. 7. Receipt of a satisfactory Division of Motor Vehicles driving record (if required for the position).*

I understand that if employed: 1. I must observe all Alaska Children's Services policies and procedures. 2. I may be transferred to another department and/or shift. 3. The amount of time I am scheduled to work may be adjusted at the sole discretion of Alaska Children's Services. 4. No Alaska Children's Services employee other than the President and CEO has the authority to enter into any employment agreement for any specific period of time and in writing. 5. I am employed without commitment to duration of employment due to fiscal uncertainties, fluctuations in student census, and other business reasons. This means that I may resign or that Alaska Children's Services may terminate the employment relationship at any time.*

Employment Verification Release: I understand that the information on this application is subject to check and verification by Alaska Children's Services and that any of the employers I have listed on my application or resume may be asked for information relative to my character and employment record with them. I hereby release from all liability and damage those individuals or companies who provide such information. Reproduced copies of this certification may be used as authorizations for the release of information between my previous employer and Alaska Children's Services.*

Alaska Children's Services

Alaska Children's Services Application for Employment

How did you hear about Alaska Children's Services?

Position Sought

Educational History

Employment History

Personal references

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