Education and Trainings

High School

School Name

Address

Dates Attended
From to
Graduate?
YesNo
Course / Degree

College

School Name

Address

Dates Attended
From to
Graduate?
YesNo
Course / Degree

Business

School Name

Address

Dates Attended
From to
Graduate?
YesNo
Course / Degree

Technical

School Name

Address

Dates Attended
From to
Graduate?
YesNo
Course / Degree

Graduate

School Name

Address

Dates Attended
From to
Graduate?
YesNo
Course / Degree

List specific trainings or special skills that may assist your job performance here at ARJ, LLC.
Be sure to include any training that pertains specifically to the human services field.

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14%

Authorizing Release of Information of References

This page gives ARJ permission to call and verify your references.

Authorization for Release of Information

To Whom It May Concern:

Please fully respond to all inquires from ARJ, LLC concerning my previous employment with your company. I specifically waive prior oral or written notice of disclosure of my personnel record information including but not limited to any performance appraisals or any disciplinary action that may have occurred during my tenure with your agency/company.

I hereby release you and your agency/company from any claimed liability arising out of any response or disclosure you might make concerning my employment. This release is intended to cover any communication, oral or written, that you might have with a representative from ARJ, LLC.

Print Name*

I authorize the Release of Information of References.*

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28%

Work History

If you have any previous work experience in the Human Services Field, please include them below.

Company 1

Name

Phone

Address

Supervisor

Job Title

Dates Employed
From to

May We Contact Employer
YesNo

Starting Salary:

Ending Salary:

Reason for Leaving

List Major Duties

Company 2

Name

Phone

Address

Supervisor

Job Title

Dates Employed
From to

May We Contact Employer
YesNo

Starting Salary:

Ending Salary:

Reason for Leaving

List Major Duties

Company 3

Name

Phone

Address

Supervisor

Job Title

Dates Employed
From to

May We Contact Employer
YesNo

Starting Salary:

Ending Salary:

Reason for Leaving

List Major Duties

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.

By checking this box, I acknowledge that the information is true and correct.*

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42%

References

Please list persons not related to you to include two professional references who were former supervisors and one personal reference.

Name

Phone

Company Name

Relationship

Years Acquainted

Name

Phone

Company Name

Relationship

Years Acquainted

Name

Phone

Company Name

Relationship

Years Acquainted

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57%

Hepatitis B Statement

I understand that due to type of occupation I have accepted, I may be exposed to blood or other potentially infectious and hazardous materials. Specifically, I may be at risk of exposure to and acquiring the Hepatitis B-Virus (HBV). I have been given the opportunity to be vaccinated with the Hepatitis B vaccine.

If I decide to decline the Hepatitis-B vaccination, I understand that I may continue to be at risk of acquiring Hepatitis-B virus.

In the future, if I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated to Hepatitis-B vaccine, I can receive the vaccination.

I accept the Hepatitis-B vaccination series. I will schedule an appointment with my doctor to receive the vaccination and turn in my receipts for reimbursement.I decline the Hepatitis-B vaccination series. I understand that I may be exposed to blood or other potentially infectious materials and may be at risk of acquiring the Hepatitis-B virus.

Check this box to confirm.*

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71%

Residency Confirmation Statement

This is to confirm that I,
HaveHave Not
lived in the state of North Carolina for the past five years.

Check this box to confirm.*

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85%

Confidentiality Statement for Employees, Contractors & Volunteers

Instructions: ARJ, LLC representatives sign this form upon employment, annually or as needed.
The representative keeps one copy and the original is filed in the personnel file.

1. I understand that ARJ, LLC has a legal and ethical responsibility to maintain individual privacy, including obligations to protect the confidentiality of individual information and to safeguard the privacy of individual information. I understand that during the course of my employment / assignment / affiliation at ARJ, LLC, I may see or hear other confidential information such as financial data and operational information pertaining to ARJ, LLC that ARJ, LLC is obligated to maintain as confidential.

2. Non-Compete Clause: During the employment period, I agree to devote ARJ, LLC’s best efforts of business time and attention as needed to properly advise the company regarding the business affairs and the performance of duties as an employee of ARJ, LLC to render such services as directed by the Company. During the employment period, I agree that I will not become engaged in or render services for any business that prevents or interferes with the employment of the Company.

As a condition of my employment/ assignment/ affiliation with ARJ, LLC, I understand that I must sign and comply with this agreement. By signing this document, I understand and agree that:

1. I will disclose PHI/ or confidential information only if such disclosure complies with ARJ, LLC policies, and is required for the performance of my job.*

2. My personal access code(s), user ID(s), access key(s) and password(s) used to access computer systems or other equipment are to be kept confidential at all times.*

3. I will not access or view any information other than what is required to do my job. If I have any question about whether access to certain information is required for me to do my job, I will immediately ask my supervisor for clarification.*

4. I will not discuss any information pertaining to ARJ, LLC in an area where unauthorized individuals may hear such information (for example, in hallways, on public transportation, at restaurants, and at social events). I understand that it is not acceptable to discuss any Be Well information in public areas even if specifics such as an individual’s name are not used.*

5. I will not make inquiries about any Be Well information for any individual or party who does not have proper authorization to access such information.*

6. I will not make unauthorized transmissions, copies, disclosures, inquiries, modifications, or purgings of Individual Information or Confidential Information. Such unauthorized transmissions include, but are not limited to, removing and/or transferring PHI or Confidential Information from ARJ, LLC’s computer system to unauthorized locations (for instance, home).*

7. Upon termination of my employment/assignment/affiliation with ARJ, LLC, I will immediately return all property (e.g. keys, documents, ID badges, etc.) to ARJ, LLC.*

8. I agree that my obligations under this agreement regarding Individual Information will continue after the termination of my employment / assignment / affiliation with ARJ, LLC.*

I understand that violation of this Agreement may result in disciplinary action, up to and including termination of my employment/assignment/affiliation with ARJ, LLC and/or suspension, restriction or loss of privileges, in accordance with ARJ, LLC’s policies, as well as potential personal civil and criminal legal penalties. I understand that any Confidential Information or Individual Information that I access or view at ARJ, LLC does not belong to me. I have read the above agreement and agree to comply with all its terms as a condition of continuing my employment.

By checking this box and submitting this form, I acknowledge and agree with ARJ's terms and conditions.*

You can attach your Background Check PDF here or send it in a separate email.

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