1.864.260.4515

info@acdsnb.org

212 McGee Road Anderson, SC 29625

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Employment Application

Home Employment Application

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Date
MM slash DD slash YYYY
Name*
First Middle Last
Preferred Name (First Name Only, please)*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email*

Please list the email that you would like for us to use to contact you. This is our most common method of contacting you, so please use an email address that you use and check it often.
Primary Contact Number*
Secondary Contact Number
How did you hear about this job opening?*

If you were referred by a current employee, please list their first and last name.
Position for which you are applying:*
Have you ever worked for the Anderson County DSN Board?*
- Yes
- No
If yes, when and what was your position? If you were a DSP, list the name of the facility in which you worked.
Do you have any relative(s) currently employed by the Anderson County DSN Board?*
- Yes
- No
If yes, what is the person's name and what is your relationship to this person?
Do you have a relative(s) receiving services from the Anderson County DSN Board?*
- Yes
- No
If yes, what is the persons name and what is your relationship to that person?
All positions with our agency require the ability to drive an agency vehicle. Do you have a valid state issued drivers license?*
- Yes
- No
If you are hired, you will have to provide a ten year driving record. Please be sure that you will be able to do that.
Please list the state in which your drivers license was issued.*
Have you been a South Carolina resident for at least 1 year?*
- Yes
- No
If "no" please list your most recent place of residency.
Are you legally eligible to work in the United States?*
- Yes
- No
Have you been convicted of a crime, other than a minor traffic violation?*
- Yes
- No
If you have ever been convicted of a misdemeanor or felony criminal offense (other than in a Juvenile Court), you MUST list this information (unless you have taken steps to expunge your record.) This includes fraudulent checks, driving under suspension, disorderly conduct, shoplifting, etc. *Please note that conviction of a criminal offense does not bar you from employment in all cases; each conviction is evaluated individually. However, failure to list convictions is considered falsification of the application and WILL BE grounds for termination, if hired. It is your responsibility to know what is on your criminal record. If you have charges on your record that appear without a court disposition (result) you may be asked to provide that information if selected for employment. If you have questions, please inquire before you complete your application. PLEASE NOTE THAT NOT ANSWERING THIS QUESTION WILL DEEM YOUR APPLICATION AS INCOMPLETE AND IT WILL NOT BE CONSIDERED.
If yes, please provide dates and details.
Have you been involved in a substantiated case of abuse or neglect?*
- Yes
- No
If yes, please provide dates and details.

Employment Desired
Type of Employment Desired
- Full Time
- PRN (Part time as needed)
- I want full time but will consider PRN until it becomes available
Please select your preference of shift.
- Second Shift
- Third Shift
Are you willing and able to work overtime as directed?
- Yes
- No
Date available for work
MM slash DD slash YYYY
Desired salary or hourly rate of pay*
Resume
Max. file size: 256 MB.
You may attach your resume, if applicable, but the following questions should be answered in order for your application to be considered complete
Employer
Contact Person
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Telephone Number
Job Title*
Reason for Leaving
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Job Duties
May we contact for a reference?
- Yes
- No
Employer
Contact Person
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Telephone Number
Job Title
Reason for Leaving
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Job Duties
May we contact for reference?
- Yes
- No
Employer
Contact Person
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Telephone Number
Job Title
Reason For Leaving
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Job Duties
May we contact for reference?
- Yes
- No

Education
Do you have a High School Diploma or GED?*
- High School Diploma
- GED
Please be prepared to submit verification of this requirement should you be offered employment.
If you do not have a High School Diploma or GED, are you willing to take a competency test if offered employment?
- Yes
- No
Education 2
Name of College or Technical College
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of Years Attended
Did you receive a degree?
- Yes
- No
Type of diploma/degree?
Course of Study
Do you have any special skills or licenses that may benefit your performance in the applied position? If so, please list.

References
List names and telephone numbers of three business/work references who are not related to you and who are not previous supervisors. If not applicable, list three school references or personal references who are not related to you.
Name
First Last
Title
Relationship
Telephone
Email
Years Known
Name
First Last
Title
Relationship
Telephone
Email
Years Known
Name
First Last
Title
Relationship
Telephone
Email
Years Known

Applicant's Statement
It is understood and agreed upon that any misrepresentation by me on this application or in any interview(s) will be sufficient cause of cancellation of this application and/or separation from the Anderson County DSN Board(ACDSNB) if I have been employed.

I give the ACDSNB the right to investigate all references and to secure additional information about me, if job-related. This includes Law enforcement and driving records. I hereby release from liability the ACDSNB and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The ACDSNB is an Equal Opportunity Employer. The ACDSNB does not discriminate in employment and no question on this application is used for purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.

I understand that just as I am free to resign at any time, the ACDSNB reserves the right to terminate my employment at any time with or without cause and without prior notice, so long as there is no violation of applicable federal or state law.

I understand that no representative of the ACDSNB has the authority to make any assurances to the contrary. THIS APPLICATION DOES NOT IMPLY ANY CONTRACTUAL OBLIGATION.

I understand it is the policy of the ACDSNB not to refuse to hire a qualified individual with a disability because of this person's need for an accommodation that would be required by the AMERICANS WITH DISABILITIES ACT.

If employed, I understand that I am required to complete all designated training and orientation and abide by all rules and regulations of the ACDSNB.

If I am hired, I understand I will be required to provide proof of identity and legal authorization to work in the United States and the federal immigrations laws require me to complete an I-9 form in this regard.

By typing my name in the "Signature" field below and submitting this application for employment, I certify that I have read and reviewed the information provided in this application, and I certify that I understand all parts of it and have answered all questions completely and fully to the best of my ability.
Agreement*
- My checking this box, I confirm that I have read the above "Application Statement".
Electronic Signature*
Date
MM slash DD slash YYYY
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Location

214 McGee Road
Anderson, SC 29625

Opening Hours

Monday – Friday
8:30 AM – 5:00 PM

* After Hours Non-Medical Emergencies Call
864-642-8843

Contact Us

1.864.260.4515
info@acdsnb.org

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