Capital City C.I.R.C.L.E.S Initiative
Date of Application:
2621 Northgate Lane, Ste. 10
Carson City, NV 89706
Professional Service Contract Application
APPLICATIONS NOT FILLED OUT COMPLETELY WILL BE REJECTED.
C.I.R.C.L.E.S. is an equal opportunity organization. No question on this application is asked for the purpose of excluding from
consideration any applicant because of race, color, gender identity, genetic information, religion, sex, sexual orientation, age, national
origin, veteran’s status, disability, or any other characteristic protected under local, state or federal law. ANY APPLICANT WILL BE
IMMEDIATELY REJECTED FOR CONSIDERATION OR, IF HIRED, WILL HAVE THEIR CONTRACT TERMINATED FOR GIVING
FALSE INFORMATION OR OMISSION ON THIS APPLICATION (AND/OR ACCOMPANYING RESUME, IF ANY) OR FAILING TO
ACCURATELY PROVIDE INFORMATION REQUESTED. IF HIRED, THE SERVICE CONTRACT IS FOR A FIXED TERM OF TWO (2)
YEARS WITH AN OPPORTUNITY TO RENEW BY MUTUAL AGREEMENT OF THE PARTIES AND THE ORGANIZATION OR THE
CONTRACTORCAN TERMINATE THE CONTRACT AT ANY TIME, WITH OR WITHOUT CAUSE, UPON THIRTY (30) DAYS
WRITTEN NOTICE.
Applicant Information
Full Name:
First
M.I.
Last
Address:
Street Address
Apartment/Unit #
City
State
Home Phone:
(
)
Position Desired:
C.I.R.C.L.E.S. Coach
ZIP Code
Cell Phone:
(
Date Available:
Compensation
$20/hour or $20,800/year
Referred by:
Are you 18 years of age or older?
Is there any reason you would be unable to work flexible hours?
YES
)
NO
The Company does not allow more than three (3) instances of missed time with in the first ninety (90) days.
This question is not designed to elicit information about an applicant’s disability. Please do not provide information about the existence
of a disability, particular accommodation, or whether the accommodation is necessary. These issues may be addressed at a later
stage to the extent permitted by law.
YES
NO
YES
NO
YES
NO
NO
Do you have any
planned time off?
Are you able to fulfill the requirements of this position with or without reasonable accommodation?
Are you working or planning on working
more than one job?
Have you ever worked for this organization
under your own or another name?
Are you authorized to lawfully work in the
United States and provide documentation?
YES
YES
NO
If no,
age?
YES
NO
Need more
information about
the ‘essential
functions’
If yes provide details:
(FT/PT) Company, Position
If yes, provide
name/dates:
Do you have reliable transportation to work?
YES
NO
Exclude organizations the name or character of which indicates the religion, race, sex, color or national origin of its members.
List professional organizations or other activities:
ANSWERING “YES” TO EITHER PART OF THE FOLLOWING QUESTION DOES NOT CONSTITUTE AN AUTOMATIC EXCLUSION
FROM CONSDIERATION. FACTORS SUCH AS DATE OF THE OFFENSE, SERIOUSNESS AND NATURE OF THE VIOLATION,
REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN INTO ACCOUNT.
Have you pleaded “guilty” or “no contest” to or been convicted of a crime under your own or another name?
(Do not include traffic tickets.) Attach more paper if required.
If “yes” state
crime:
Date of offense:
Charge:
Location:
YES
NO
Disposition of
case:
Education
Have you obtained a high school diploma or GED certificate?
High School:
Did you graduate?
YES
NO
Subject
Studied:
City/State/Zip:
Street Address:
YES
NO
Subject
Studied:
Technical / Other:
Did you graduate?
NO
Street Address:
College:
Did you graduate?
YES
City/State/Zip:
Street Address:
YES
NO
Subject
Studied:
City/State/Zip:
Certification(s)
Employment History
Most recent or current employer first. Do not substitute with resume.
From:
Job Title:
To:
Reason for
Leaving:
Starting
Salary:
Ending
Salary:
$
$
Company:
Phone:
Street Address:
Supervisor:
City/State/Zip:
May we contact your previous
supervisor as a reference?
YES
NO
YES
NO
YES
NO
Responsibilities:
From:
Job Title:
To:
Reason for
Leaving:
Starting
Salary:
Ending
Salary:
$
$
Company:
Phone:
Street Address:
Supervisor:
City/State/Zip:
May we contact your previous
supervisor as a reference?
Responsibilities:
From:
Job Title:
To:
Reason for
Leaving:
Starting
Salary:
Ending
Salary:
$
$
Company:
Phone:
Street Address:
Supervisor:
City/State/Zip:
May we contact your previous
supervisor as a reference?
Responsibilities:
Have you ever been discharged, fired, or asked to resign?
YES
NO
If yes, explain:
Explain any gaps in your employment of more than three (3) months, other than those due to personal illness, injury, or disability.
References
Please list three references. (Persons not related to you that you have known for at least one year. One must be a previous employer.)
Name:
Phone:
Position or Relationship:
Years Known:
Please list any other job-related skills or experiences you would like us to consider (computers, etc.):
Military Service
Branch:
Rank at
Discharge:
Type of
Discharge:
From:
To:
Specialty(s):
If other than honorable, explain:
Applicant Disclaimer
I certify that my answers are true and complete to the best of my knowledge. I understand that any false statement, omission, or
misrepresentation on this application (and/or accompanying resume, if any) is sufficient cause for refusal to hire, or contract
termination if I have been hired, no matter when discovered by Capital City C.I.R.C.L.E.S Initiative (Organization).
I understand that any hiring is conditioned on a reference check. I expressly authorize, without reservation, the Organization to
thoroughly investigate all statements contained in my application and/or resume and I authorize my former clients, employers and
references to disclose information regarding my former contracts, employment, character and general reputation to the
Organization without giving me prior notice of such disclosure. In addition, I release the Organization, any former clients,
employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such
investigation or disclosure.
I understand that this organization does not unlawfully discriminate in hiring and no question on this application is used for the
purpose of limiting or eliminating any applicant from consideration on any basis prohibited by applicable local, state or federal
law.
If I am to be hired by the Organization, I will be required to attest to my identity and hiring eligibility, and to present documents
confirming my identity and hiring eligibility. I cannot be hired if I cannot comply with these requirements.
If I am offered a contract I agree to submit to a drug test before starting work. If hired, I also agree to submit to a drug test at any
time deemed appropriate by the Organization and as permitted by law. I consent to such tests, and I request that the examining
doctor disclose to the Organization the results of the examination, which results shall remain confidential.. I understand that my
contract t, to the extent permitted by law, is contingent upon satisfactory drug tests, and if I am hired a condition of my hiring will
be that I abide by the Organization’s Drug and Alcohol Policy.
I understand and agree that if I am hired, my service contract will be for a fixed term of two (2) years with an opportunity to renew
by mutual consent of the parties. Said contract may be terminated at any time, with or without cause, at the option of either
myself or the Organization upon thirty (30) days written notice.
I understand that filling out this form does not indicate there is a contract available and does not obligate the Organization to hire.
If hired, I agree to abide by all Organization rules, policies and procedures. The Organization retains the right to revise its policies
or procedures, in whole or in part, at any time.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT DISCLAIMER.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Disclaimer.
Signature:
Date: