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Job Application

Job Description
QMHP Registration Information

Support Systems, Inc.

1120 Bypass Road-Vinton, VA-24179

540-767-2667(P)

540-767-2669(F)

supportsystemsllc@gmail.com

Employment Application

Position Applying For:

Support Systems, Inc. is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any other characteristic protected by law.

Applicant Information

Full Name:

Date:

Current Address:

Street Address Apartment/Unit#

City State ZIP Code

Date of Birth: SSN:

Drivers License#:

Phone: Email:

Date Available: Desired Salary:

Are you a citizen of the United States?

YES NO

If no, are you authorized to work in the U.S.?

YES NO

Have you or any relatives ever worked for this company?

YES NO

If yes, name and dates:

Have you ever been convicted of anything other than a minor traffic violation?

YES NO

If yes, explain:

Have you ever been convicted or terminated for Medicaid fraud?

YES NO

If yes, explain:

Education

From:

To:

Did you graduate?

YES NO

Diploma:

College:

Address:

From:

To:

Did you graduate?

YES NO

Degree:

High School:

Address:

From:

To:

Did you graduate?

YES NO

Degree:

Other Education:

References

Please list three professional references.

Full Name:

Relationship:

Company:

Phone:

Address:

Full Name:

Relationship:

Company:

Phone:

Address:

Full Name:

Relationship:

Company:

Phone:

Address:

Previous Employment

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:$

Ending Salary:$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YES NO

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:$

Ending Salary:$

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

YES NO

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:$

Ending Salary:$

Responsibilities:

From:

To:

Reason for Leaving:

Specialized Skills & Knowledge

Please list any skills or knowledge that shows your ability to perform the job for which you are applying, (examples are computer experience, volunteer experience, software knowledge, etc.)

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature:

Date:

Information Release

I,, understand it will be necessary for Support Systems, INC to conduct a background check regarding my driving record, criminal history, personal references, and employment.

I authorize Support Systems, INC to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for purposes of participating in a mentoring program.

Further, I provide permission for Support Systems, INC to conduct the same investigation of my background in previous states in which I have resided.

Signature:

Date:

Please list any other cities, states, and dates of residency during the past 10 years.

City	State	From (Month/Year)	To (Month/Year)