Employment Application

Independent Capacity System, Inc (ICS, Inc.) is an Equal Opportunity Employer and does not discriminate because of race, color, age, sex, religion, national origin, disability, veteran’s status, marital status, or other status protected by law. It is the policy of Independent Capacity System, Inc (ICS, Inc.) to recruit, hire, promote for all job classifications on the basis of merit, qualifications and competence. This applies to all categories of employment.

Note: All fields are required. If a field does not apply, please write "n/a".

Position

Company Applying For: Independent Capacity System Independent Homes Independent Capacity Transportation

Select Desired Work Schedule

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
	7:00am - 2:00pm	7:00am - 2:00pm	7:00am - 2:00pm	7:00am - 2:00pm	7:00am - 2:00pm
	7:45am - 3:00pm	7:45am - 3:00pm	7:45am - 3:00pm	7:45am - 3:00pm	7:45am - 3:00pm
	8:45am - 4:00pm	8:45am - 4:00pm	8:45am - 4:00pm	8:45am - 4:00pm	8:45am - 4:00pm
8:00am - 11:00pm	2:00pm - 8:00pm	2:00pm - 8:00pm	2:00pm - 8:00pm	2:00pm - 8:00pm	2:00pm - 8:00pm	2:00pm - 8:00pm
8:00am - 8:00pm	2:00pm - 11:00pm	2:00pm - 11:00pm	2:00pm - 11:00pm	2:00pm - 11:00pm	2:00pm - 11:00pm	8:00am - 8:00pm
9:00am - 11:00pm	3:00pm - 11:00pm	3:00pm - 11:00pm	3:00pm - 11:00pm	3:00pm - 11:00pm	3:00pm - 11:00pm	9:00am - 11:00pm
11:00pm - 9:00am	11:00pm - 9:00am	11:00pm - 9:00am	11:00pm - 9:00am	11:00pm - 9:00am	11:00pm - 9:00am	11:00pm - 9:00am

Can we call you to offer you another shift, if your desired shift is not available? Yes    No

Are you willing to work overtime? Yes    No

Are you willing to work mandatory overtime? Yes    No

Would you be able to work weekends? Yes    No

How far are you willing to travel? Yes    No

Desired salary

Personal

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Date of Birth:

A copy of the application will be sent to this email address.

Are you currently involved in any form of drug or alcohol abuse?  Yes No

Is there any reason you would be unable to perform all of the physical duties of the position of which you have applied?
 Yes No

Have you ever been discharged or asked to resign by an employer?  Yes No

Are there foreign languages you can interpret or translate?  Yes No

Are you lawfully authorized to work in the United States?  Yes No

Have you ever committed, been convicted of, plead guilty to, or plead nolo contendre to a felony or a misdemeanor (excluding traffic violations) in Virginia or outside of the jurisdiction of Virginia?  Yes No

Are you involved in any pending or future malpractice claims?  Yes No

Have you ever worked with intellectually disabled adults before? Yes No 

Personal/Professional/Technical References

Reference 1:

Reference 2:

Reference 3:

Reference 4:

Reference 5:

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Education

Indicate highest grade attained:
 1  2  3  4  5  6  7
 8  9  10  11  12  13+

Did you graduate?  Yes No

If not, have you passed a GED test?  Yes No

High School or Preparatory:

College:

Graduate Work:

Business School or Technical School or additional Graduate Work:

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Training and Certificate Information

Do you have a valid driver’s license?  Yes No

Have you had any accidents during the past three years?  Yes No

Have you had any moving violations during the past three years?  Yes No

*Please make sure we retain a copy of all certifications, licenses (to include driving license) and an official abstract from Department of Motor Vehicles dated within 14 days of employment*

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Employment History

Please describe all paid, military, and applicable voluntary experience starting with the most recent. You should highlight your knowledge, skills, and abilities that best demonstrate your qualifications for the position. This information is essential in evaluating your qualifications and selecting the appropriate applicant for the position. You may list significantly different jobs within the same organization as separate items.

Present Employer or Most Recent Employer

May we contact your present supervisor?  Yes No

 Full-time Part-time |

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Previous Employer

 Full-time Part-time |

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Previous Employer

 Full-time Part-time |

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Read Carefully

In the event my application is accepted for consideration, I authorize an investigation of all statements contained in this application. I also hereby release any and all persons, companies, or agencies responding to such investigation from any damage due to releasing any information they have regarding me, whether or not it is in their records, pertaining hereto. I understand that all reference information provided will be kept confidential.

I understand successful completion of the matters set forth above is a prerequisite to employment or continued employment. I swear and affirm that the information contained in this application is true and accurate. I further understand that misrepresentation of facts asked for on this application will generally result in my application not being further considered by Independent Capacity System, Inc (ICS, Inc.) and / or will generally result in dismissal from employment no matter when discovered.

I understand that nothing contained in this employment application is intended to create an employment contract between me and Independent Capacity System, Inc (ICS, Inc.). If at some point an employment relationship is established, I also understand that my employment status will be at will, which means that my employment may be terminated by me or Independent Capacity System, Inc (ICS, Inc.) at any time, for any reason. If I am employed, I agree to comply with all of the rules and regulation of Independent Capacity System, Inc (ICS, Inc.).

Are you currently under a physician’s care or currently taking any medication?
 Yes No

Do you understand that due to your occupational exposure to blood or other potentially infectious material, you may be at risk of acquiring Hepatitis-B Virus (HBV) infection and that The Independent Capacity System, Inc (ICS, Inc.) recommends that you should consider being vaccinated before beginning employment?
 Yes No

I have received and/or reviewed a copy of the Independent Capacity System, Inc (ICS, Inc.) Handbook and agree to read it and use it for reference. I understand that this booklet is intended as a guide for personnel policies and benefits, and general information, and that it is not intended to be an inclusive, not a contract for employment.

I further understand that management reserves the right to make changes in these guidelines or in their application as deemed necessary and / or appropriate. I understand that these changes can be made without notice to employee.

I understand I may receive disciplinary action up to and including termination for violating policies and / or procedures contained in this handbook.

"Independent Capacity System would like to thank you for considering joining our team!”

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Attachments

Please attach any additional files you would like to send (e.g. resume, letters of reference)

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