H.A.T.S. - Employment Application

Habilitation & Training Services of Tennessee, Inc.

Employment Application

HATS is an equal opportunity employer and will not discriminate in the hiring process on the basis of
sex, religion, race, color, creed, age, disability, military or veteran status, national origin or any other protected status.

PERSONAL INFORMATION
*Last Name	*First Name	*Social Security Number:
*Present Address:	*City:	*State:	*Zip:
Previous Address (if less than 3 yrs.):	City:	State:	Zip:
*Are you 18 years or older? YESNO	Home Phone:	Cell Phone:

DESIRED EMPLOYMENT
Position:	Date You Can Start:	Salary Needed:
*Are you employed now? YESNO	If so, may we inquire of your present employer? YESNO
*Ever applied to or worked with this agency before? YESNO	If so, where and when did you work for HATS?

EDUCATION
School Level	Name & Location of School	Number of Years Attended	Did you graduate?	Subjects Studied
Grammar School			YES NO
High School			YES NO
College			YES NO
Trade/ Business/ Correspondence			YES NO

Special skills and training:

FORMER EMPLOYERS Provide past work history containing a continuous description of activities over the past five years, starting with the most recent employer.
Name of Present or Last Employer 1:
Address:	City:	State:	Zip:
Starting Date:	Leaving Date:	Job Title:
Name of Supervisor:	*May we contact your supevisor? YESNO	Phone:
Description of work:
Reason for leaving:

Name of Present or Last Employer 2:
Address:	City:	State:	Zip:
Starting Date:	Leaving Date:	Job Title:
Name of Supervisor:	*May we contact your supevisor? YESNO	Phone:
Description of work:
Reason for leaving:

Name of Present or Last Employer 3:
Address:	City:	State:	Zip:
Starting Date:	Leaving Date:	Job Title:
Name of Supervisor:	*May we contact your supevisor? YESNO	Phone:
Description of work:
Reason for leaving:

REFERENCES Below, give names of three persons you are not related to, whom you have known at least five years.
Name	Address or Daytime Phone Number	Relationship	Years Acquainted

MILITARY SERVICE RECORD
Branch of Service	Discharge Date & Rank

I, the undersigned applicant, certify and affirm that, to the best of my knowledge and belief; I have or have not had a case of abuse, neglect, mistreatment, or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation I further release and authorize HATS, Inc. and the Tennessee Division of Mental Retardation Services to have full and complete access to any and all current or prior personnel or investigative records, from any party, person, business or agency, as pertains to any investigation against me of abuse, neglect, or mistreatment and to consider this information as may be deemed appropriate.

Signature: APPLICANT TO PROVIDE IF CALLED FOR INTERVIEW Date:

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application will be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the agency has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. I understand in order to be considered for employment, the application must be completed in full.

Date: Signature: APPLICANT TO PROVIDE IF CALLED FOR INTERVIEW

Acknowledgement & Consent Form
I hereby consent and authorize an investigative consumer report for background checks to be conducted if deemed appropriate by H.A.T.S., Inc. in partnership with E & A Solutions, Inc. Public records may be used in this report, such as civil and criminal records and driving records. I realize this inquiry may include information regarding my character, general reputation, a criminal background check and motor vehicle report. I release H.A.T.S., Inc. and E & A Solutions, Inc. from liability associated with obtaining that inquiry. This consumer report will be used for employment purposes and may be subject to the Fair Credit Reporting Act. I may receive a free copy of this report. Before any adverse action is taken based on this report I will receive copy of the report and notice of my rights under the FCRA.
Full Legal Name:
Address:
Maiden Name & Alias Names:
Date of Birth:		Gender:
Driver's license Number:		State Issued:
Name as it appears on license:
Social Security Number:
Signature of person representing H.A.T.S., Inc.	PROVIDED UPON APPLICANT INTERVIEW

This form was last updated:

Contact us: P.O. Box 1856 | Gallatin, TN 37066-1856 | Phone: 615.451.0974 | Fax: 615.451.0774
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