THE MARYLAND SALEM CHILDREN'S TRUST, INC. APPLICATION FOR EMPLOYMENT 605 Salem Drive Frostburg, MD 21532 P: 301.689.8176 ∙ F: 301.689.1902
PRINT, FILL IN AND MAIL / FAX. OR SUBMIT ONLINE.
POSITION APPLIED FOR
Please attach your resume
Please answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you need additional space. None of the questions on this application is intended to imply illegal references or discrimination based upon non-job-related information.
Are you seeking full-time part-time temporary employment?
When could you start work? First Name Middle Name Last Name
Address
City
State Zip
Email Address
Daytime Phone Evening Phone
If applying for the position of Teaching Parent or Overnight Awake, are you at least 21 years old? (If hired, you may be required to submit proof of age.)
Yes No Not applicable
Have you ever been convicted of a felony? Yes No If yes, please explain:
Do you have a valid driver's license? Yes No
Have you ever been charged with a driving violation? Yes No If yes, please explain:
Please enter your educational and employment background:
How did you find out about Salem?
Please state briefly why you are interested in working at Salem:
Please describe the Salem philosophy as you understand it..
Can you support Salem's philosophy? Yes No Comments:
WORK HISTORY
List names of employers in consecutive order with present or last employer first. Account for all periods of time, stating MONTH AND YEAR, including military service and any periods of unemployment. If self-employed provide firm name and business references. If additional space is needed, please continue Work History on a separate sheet of paper.
Name of Employer Supervisor
Address City State Zip
Phone
Title Pay: Start $ Final $
Duties
Reason for Leaving
Have you worked or attended school under any other name(s)? Yes No
If yes, list name(s)
Are you presently employed? Yes No
If yes, whom do you suggest we contact for reference?
Have you ever been fired from a job or asked to resign? Yes No If yes, please explain:
IN CASE OF EMERGENCY NOTIFY Name: Relationship Daytime Phone: Evening Phone:
AFFIDAVIT
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and result in my dismissal if discovered at a later date.
I understand that if I am extended an offer of employment with Salem it will be contingent upon receipt of satisfactory:
1) Personal References 2) Medical Examination 3) Criminal Background Check 4) Child Protective Services Check 5) Driving Record 6) Official Transcript/License (Professionals)
I further understand that I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required.
I understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without cause and with or without notice.
I have read, understand and, by my signature, consent to these statements.
Signature______________________________________ Date______________________ If you are submitting this form on line, you may print this page, sign it and mail or fax. Or sign it at your interview, should that occur.
It is the policy of The Maryland Salem Children's Trust to ensure equal opportunity to all individuals regardless of race, color, national origin, handicap or age.
Your application will remain active for a limited time. Ask your interviewer for details.
STATEMENT OF EMPLOYER REQUIREMENT
Code of Maryland
"Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100.00."
I hereby testify that I have received and read the above statement.
Signature______________________________________ Date______________
If you are submitting this form on line, you may print this page, sign it and mail or fax. Or sign it at your interview, should that occur.
(This statement must be attached to all employment applications in the State of Maryland.)