Online Job Application Apply For A Job Step 1 of 2 50% This field is hidden when viewing the formDate* MM slash DD slash YYYY Name* First Last Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Referred ByTitle of Position Applying for*Will you accept:* Full Time Part Time On Call Have you worked for NVCSS?* Yes No If Yes, which facility and when?Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age).* Yes No Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?* Yes No If no, describe the functions that cannot be performed.Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential tasks.Education (A resume may be attached, but the entire application must be completed).Name of School(s)LocationNo. of Years CompletedMajor CourseDegree/Certificate Other special education/professional associations (include U.S. military service schools and experience or skills that would qualify you for the position for which you are applying).License (Professional License/Registration/Certification)TypeStateNumberExpiration Date Upload Professional License Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, tiff, tif, pdf, docx, txt, rtf, pages, doc, odt, ppt, pptx, key, odp, Max. file size: 50 MB. Upload Resume & Cover Letter Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, tiff, tif, pdf, docx, txt, rtf, pages, doc, odt, ppt, pptx, key, odp, Max. file size: 50 MB. Have you ever been involuntarily terminated from any prior employment?* Yes No If yes, give details of termination, including date of termination, employer's name and reason for termination.Please read carefully, check box by each paragraph and sign* below.* I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and NVCSS. In addition, I understand and agree that if I am employed, my employment is for no definite or determined period and may be terminated at any time, with or without prior notice, at the option or either myself or NVCSS, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the NVCSS designated representative. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. I authorize all previous employers and schools to give information needed by NVCSS for purposes of obtaining an account of my education and work experi-ence. I agree to hold any or all of them blameless and free of any liability for releasing any truthful information that is within their knowledge or records. I am aware that I will be required, as a condition of employment, to successfully complete a background check and medical examination and that any referral to a private doctor for suggested follow-up will be at my own expense. I agree to observe all rules, regulations, and policies of NVCSS. *By typing your name you providing an electronic signature and are acknowledging that you agree with the following: My signature below signifies that I recognize that my employment with NVCSS is “at will”. This means that either NVCSS or myself can terminate my employ-ment at any time with or without notice and with or without a reason. I understand the provisions of this paragraph cannot be changed unless the change is in writing.Name* First Last Date MM slash DD slash YYYY NVCSS provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This information is used to determine if our equal employment opportunity efforts are reaching all segments of the population, consistent with Federal equal employment opportunity laws. Responses to these questions are voluntary. Your responses will not be shown to the panel rating the applications, to the official selecting an applicant for a position, or to anyone else who can affect your application. This form will not be placed in your Personnel file nor will it be provided to your supervisors in your employing office should you be hired. The aggregate information collected through this form will be kept private to the extent permitted by law. See the Privacy Act Statement below for more information.Position applied forDate MM slash DD slash YYYY I learned of this job opening through (check one only) A friend or relative An advertisement (specify below) The Agency's online job listings Other means (specify below) OtherThe next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of medication and aids (except eyeglasses) or the help of another person.Do you have any disabilities or serious health conditions which may limit your ability to perform the job? Yes No If yes, what can be done to accommodate your limitations and if necessary to provide assistance in the recruitment and testing process? If you have special needs, please fill out below and call (530) 241-0552.Privacy Act Statement: This Privacy Act Statement is provided pursuant to 5 U.S.C. 552a (commonly known as the Privacy Act of 1974). The authority for this form is 5 U.S.C. 7201, which provides that the Office of Personnel Management shall implement a minority recruitment program, by the Uni-form Guidelines on Employee Selection Procedures, 29 C.F.R. Part 1607.4, which requires collection of demographic data to determine if a selection procedure has an unlawful disparate impact, and by Section 501 of the Rehabilitation Act of 1973, which requires federal agencies to prepare affirmative action plans for the hiring and advancement of people with disabilities. Data relating to an individual applicant are not provided to selecting officials. This form will be seen by Human Resource personnel in the Office of Personnel Management (who are not involved in considering an applicant for a particular job) and by Equal Employment Opportunity Commission officials who will receive aggregate, non-identifiable data from the Office of Personnel Management derived from this form. Purpose and Routine Uses: The aggregate, non-identifiable information summarizing all applicants for a position will be used by the Office of Personnel Management and by the Equal Employment Opportunity Commission to determine if the executive branch of the Federal Government is effectively recruiting and selecting individuals from all segments of the population. Effects of Nondisclosure: Providing this information is voluntary. No individual personnel selections are 4 made based on this information. There will be no impact on your application if you choose not to answer any of these questions. Paperwork Reduction Act Statement: The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et. seq,) requires us to inform you that this information is being collected for planning and assessing affirmative employment program initiatives. Response to this request is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. The estimated burden of completing this form is five (5) minutes per response, including the time for reviewing instructions. Direct comments regarding the bur-den estimate or any other aspect of this form to [INSERT: Agency name and address] and to the Office of Management Budget, Office of Information and Regulatory Affairs, Washington, DC 20503.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. ALL STAFF2015-08-12T15:24:09-07:00
