Fields marked with an asterisk (*) must be filled out before submitting.
|Please identify the racial/ethnic category you most closely identify with by clicking the button next to the category. || I choose not to identify my race/ethnicity
White (not Hispanic or Latino)
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Two or more races/ethnicities (not Hispanic or Latino)
Hispanic or Latino
Please check any/all boxes for the descriptions below that apply to you.
| Individual with a Disability Status Code|
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person’s major life activities, or who has a record of such impairment.
| Vietnam-Era Veteran Status Code|
Vietnam-Era Veteran means a person who:
- Served on active duty for a period of time more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred: a) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b) between August 5, 1964, and May 7, 1975, in all other cases; OR,
- Was discharged or released from active duty for a service-connected disability if any part of usch active duty was performed: a) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b) between August 5, 1964, and May 7, 1975, in all other cases.
| War/Campaign/Expedition Veteran Status Code|
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
| Armed Forces Service Medal Veteran|
Armed Forces Service Medal Veteran means: A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded.
| Disabled Veteran Status Code|
Disabled Veteran means:
- A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws of Veteran Affairs; OR,
- A person who was discharged or released from active duty because of a service-connected disability.
| Recently Separated Veteran|
Any veteran during the three-year period beginning on date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval or air service.
|Separation Date (mm/dd/yyyy)|
I authorize the investigation of all statements contained in this application, and release from all liability any persons or employers supplying such information, and I also release the company from all liability that might result from making the investigation. I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or any other required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered. I understand that, if hired, my employment will be at-will, meaning that either party can end the employment relationship at any time and for any or no reason. I also understand any employment offer will be contingent upon my providing, within three working days of employment, valid proof of identity and eligibility to work in accordance with the Immigration Reform and Control Act of 1986.
I understand and hereby agree that past employers, educational institutions and/or the military may be contacted by Family Development Services, Inc. for references.
I understand that:
- A complete background investigation may be conducted and that for certain positions my employment or consideration for employment is subject to verifications of the satisfactory condition of one or more of the following:
- Driving Record
- Credit History
- Criminal or Pending Convictions
- Post-Offer Physical Examination
- Test for Drugs and/or Alcohol
- Employment with the Company will be contingent upon a negative drug test result and is contingent upon favorable results of a physical and TB test.
I attest that I have never been named a substantiated perpetrator in an investigation of child abuse or neglect and I understand that an annual review will be conducted by the Indiana Department of Child Services. If during any review it is reported that I have been named a substantiated perpetrator of child abuse or neglect, I understand that my employment will be terminated.
| * I have read and reviewed the information provided in this application and the above statements. By signing this application for employment, I certify that I understand all parts of it and have answered all questions completely and fully.|