1. CompanyName
Date
APPLICATIONFOREMPLOYMENT
PleasePrintClearly
PleaseAnswerAllQuestions.RésumésAreNotA SubstituteForA CompletedApplication.
Weareanequalopportunityemployer.Applicantsareconsideredforpositionswithoutregardtoveteranstatus,uniformeds
ervice
memberstatus,race,color,religion,sex,nationalorigin,age,physicalormentaldisability,geneticinformationoranyotherc
ategoryprotectedbyapplicablefederal,state,orlocallaws.
FULL
CIRCLE
YOUTH
AND
FAMILY
SERVICES,
PLLC.ISANATWILLEMPLOYERASALLOWEDBYAPPLICABLESTATELAW.THISMEANSTHATREGARDLESSOFANYPROVISIONINT
HISAPPLICATION,IFHIRED,FCYFSORIMAYTERMINATETHEEMPLOYMENTRELATIONSHIPATANYTIME,FORANYR
EASON, WITHORWITHOUTCAUSEORNOTICE.
PositionAppliedFor
(list onlyone)
TelephoneNumber(
)
-
Name
_____CellularTelephoneNumber(
)
________-__________
PresentAddress
Street,Apartment,orUnitNumber
City
State
Howlonghave youlivedthere
/
Zip
_Years/Months
EmailAddress(optional)
DesiredSalary/HourlyRate
If
undertheageof18,canyouproducethenecessaryworkcertificateatthetimeof employment?
Typeofemploymentdesired?
Full-time
Areyou willingto workovertime?
Yes No
Yes
No
Part-time
(SpecifyHours)
Dateonwhichyoucanstartwork ifhired
HaveyoupreviouslyappliedforemploymentwithFull Circle Youth and Family Services, PLLC?Yes No
IfYes,whenandwheredidyouapply?
HaveyoueverbeenemployedbyFull
Circle?Yes No
IfYes,providedatesofemployment,location,andreasonforseparationfrom employment.
CRIMINALHISTORY
FCYFS,
PLLC.requirespre-employmentcriminalhistorybackgroundchecks.Thisaction
istaken
organizationisnotnegligentinhiringindividualswhomayposeathreattothepersonsservedorstaffoftheorganization.
toensure
thatthe
Applicantsthatareofferedemploymentwillbeinformedthatsaidemploymentwillbecontingentuponobtainingacriminalhistory/backgroundcheckfromtheOklahomaSta
teBureauofInvestigation(OSBI)orotherapprovedorganizationpriortobeginningemployment.The
applicant/employee/contractorisresponsibleforthecostofthecriminalhistory/backgroundcheck.TheClinicalDirectormaydecidetorescindtheofferofemploymentbase
donthereportfindings.Noclinicalstaffinvolvedinservicedeliverywillbemadeanofferofemploymentorcontractshouldbackgroundcheckfindingshaveviolationsinvolving
offensestochildrenordomesticviolence,oronacase-by-casebasisthatmaycreateareasonforconcern.
Allcriminalhistorybackgroundreportsshallbetreatedas
confidentialinformation.Ifan
applicantprovides
anyinaccurateinformation,thatpersonwillnotbeconsideredfurtherfortheposition.Iftheorganizationlearnsthatanyinformationaboutacriminalhistoryprovidedbyacurr
entemployee/contractorisinaccurate,thatemployee/contractorissubjecttodiscipline.However,employee/contractorswillbegivenanopportunitytoexplainanyinaccur
acies.Ifasatisfactoryexplanationisnotgiven,theemployee/contractormaybeimmediatelyterminatedfromemployment.

2. 1. Haveyoueverpleadnocontest,nolocontendere,orguiltytoamisdemeanorcrime,orbeenconvictedofami
sdemeanorcrime?
YesNo
QuestionTwo:
2. Haveyoueverpleadnocontest,nolo contendere,orguiltytoafelonycrime,orbeen convicted
ofafelonycrime?YesNo
NOTE:Answering“yes”toeitherquestiononeorquestiontwoabovedoesnotconstituteana u t o m a t i c bart o employment.Full
Circlewillconsiderthenatureofthecrime,itsseriousness,thesubstantialrelationtotheposition’sfunctionsandqualifications,thenumber
ofoccurrences,theapplicant’sageatthetimeofthecrime,thetimeelapsedsincethecrime,the
applicant’sentireworkandeducationalhistory,employmentreferencesandrecommendations,andthebusinessnecessityofanyexclus
ionwhenrequiredbystate,local,orfederallaw.
Ifyouansweredyestoeitherofthetwoprecedingquestions,pleasegivedatesanddetailsforeachincident:
Haveyoueverinitiatedanactof violenceintheworkplace?
YesNo
IfYes,pleaseprovidethedate(s)andexplainsothatindividualcircumstancescanbeconsidered.(A“Yes”answerwillnotnecessarilydisqu
alifyyoufrom employment.)
Listallspecialtechnicalskillsthatyoufeelqualifyyouforthejobforwhich
youareapplying(forexample,computerprogramming/language,software,equipmentoperation,specialtoolsormachines,etc).
Education
SchoolNameandLocation(
Address,City,State)
Courseof
Study
Graduate?
#ofYearsC
ompleted
HighSchool
College
Bus./Tech./Tradeo
rPostCollege
HonorsReceived
If applicable,listbelowanyothernamesbywhichyouhavebeenknownwhichmaybenecessarytoallowustoconfirm
yourworkandeducationalrecord.Forexample,changeofname,useofanassumedname,nickname,etc.
Degree/Major

3. WORKEXPERIENCE
Pleaselistthenamesofyourpresentand/orpreviousemployersinchronological
orderwithpresentormostrecentemployerlistedfirst.Provideinformationforatleastthemostrecentten(10)yearperiod.Attachadditional
sheetsifneeded.Ifselfemployed,supplyfirmnameandbusinessreferences.Youmayincludeanyverifiableworkperformedonavolunteerbasis,internships,or
militaryservice.Yourfailuretocompletelyrespondtoeachinquirymaydisqualifyyouforconsiderationfromemployment.Donotanswer“s
eeresume.”
Employer
NameAddressTypeof Business
Telephone(
)
-
DatesEmployed
From
/
/
To
JobTitle
/
Duties
Supervisor’sName
/
Maywecontact?
Yes No,whynot?
NoIf
WagesStart
Final
ReasonforLeaving
Whatwillthis employersay wasthereasonyouremploymentterminated?
Howmuchnoticedidyougivewhenresigning?Ifnone,explain.
Employer
Name
Telephone(
Address
)
-
DatesEmployed
Typeof Business
From
/
/
To
JobTitle
/
Duties
Supervisor’sName
/
Maywecontact?
Yes
NoIfNo,whynot?
WagesStart
Final
ReasonforLeaving
Whatwillthis employersay wasthereasonyouremploymentterminated?
Howmuchnoticedidyougivewhenresigning?Ifnone,explain.
Employer
Name
Telephone(
Address
)
-
DatesEmployed
Typeof Business
From
/
/
To
JobTitle
/
Duties
Supervisor’sName
/
Maywecontact?
Yes No,whynot?
NoIf
WagesStart
Final
ReasonforLeaving
Whatwillthis employersay wasthereasonyouremploymentterminated?
Howmuchnoticedidyougivewhenresigning?Ifnone,explain.
Haveyoueverbeenterminatedoraskedtoresignfromanyjob? 
Yes No.
natedbymutualagreement? 
Yes No
Haveyoueverbeengiventhechoiceto resignratherthanbeterminated? 
Yes No
vethreequestions,pleaseexplainthecircumstancesofeachoccasion.
IfYes,howmanytimes?
_Hasyouremploymenteverbeentermi
IfYes,howmanytimes?
_
IfYes,howmanytimes?
_IfyouansweredYestoanyoftheabo

4. REFERENCES
Pleaselistthenamesofadditionalworkrelatedreferenceswemaycontact.Individualswithnopriorworkexperiencemaylistschoolorvolunteer-relatedreferences.
NAME
POSITION
COMPANY
WORKRELATIONSHIP
(i.e., supervisor,coworker)
TELEPHONE
Pleaselistthenamesofpersonalreferences(notpreviousemployersorrelatives)whoknowyou wellthatwemaycontact.
NAME
OCCUPATION
ADDRESS
TELEPHONE
NUMBEROFYEA
RS KNOWN
APPLICANTCERTIFICATION
IunderstandandagreethatifdrivingisarequirementofthejobforwhichIamapplying,myemploymentand/orcontinuedemploymentisco
ntingentonpossessingavaliddriver’slicenseforthestateinwhichIresideandautomobileliabilityinsurancein
anamountequaltotheminimumrequiredbythestatewhereIreside.
IunderstandthatFull
Circlemaynowhave,ormayestablish,
ad r u g -free
work placeord r u g a n d /or
alc oholtestingprogramconsistentwithapplicablefederal,state,andlocallaw.IfFull
CirlcehassuchaprogramandIamofferedaconditionalofferofemployment,Iunderstandthatifapre-employment(postoffer)drugand/oralcoholtestispositive,theemploymentoffermaybewithdrawn.Iagreetoworkundertheconditionsrequiringadrugfreeworkplace,consistentwithapplicablefederal,state,and local law.Ialsounderstandthatall employeesofthelocation,pursuantto
Full
Circle’spolicyandfederal,state,andlocallaw,maybesubjecttourinalysisand/orbloodscreeningorothermedicallyrecognizedtestsdesi
gnedtodetectthepresenceofalcoholorillegalorcontrolleddrugs.Ifemployed,Iunderstandthatthetakingofalcoholand/ordrugtestsisac
onditionofcontinualemploymentandIagreetoundergoalcoholanddrugtestingconsistentwithFull
Circle’spoliciesandapplicablefederal,state,andlocallaw.
IfemployedbyFull
Circle,IunderstandandagreethatFull
Circle,totheextentpermittedbyfederal,state,andlocallaw,mayexerciseitsright,withoutpriorwarningornotice,toconductinvestigation
sofproperty(including,butnotlimitedto,
files,lockers,desks,vehicles,andcomputers)and,incertaincircumstances,mypersonalproperty.
Iunderstandandagreethatasaconditionofemploymentandtotheextentpermittedbyfederal,state,andlocallaw,Imayberequiredtosign
confidentiality,restrictivecovenant,and/orconflictofintereststatement,aswellasanagreementtoarbitrate.
Icertifythatalltheinformationonthisapplication,myrésumé,oranysupportingdocumentsImaypresentduringanyinterviewisandwillbe
completeandaccuratetothebestofmyknowledge.Iunderstandthatanyfalsification,misrepresentation,oromissionofanyinformation
mayresultindisqualificationfromconsiderationforemploymentor,ifemployed,disciplinaryaction,up
to
andincludingimmediatedismissal.
FULL
CIRCLE
YOUTH
AND
FAMILY
SERVICES,PLLC.ISANATWILLEMPLOYERASALLOWEDBYAPPLICABLESTATELAW.THISMEANSTHATREGARDLESSOFANYPROVISIONINTHIS
APPLICATION,IFHIRED,FULL
CIRCLEORIMAYTERMINATETHEEMPLOYMENTRELATIONSHIPATANYTIME,FOR
ANYREASON,
WITHOR
WITHOUTCAUSEORNOTICE.NOTHINGINTHISAPPLICATIONORINANYDOCUMENTORSTATEMENT,WRITTENORORAL,
SHALLLIMITTHE RIGHTTOTERMINATEEMPLOYMENTAT-WILL.
NO
OFFICER,EMPLOYEEORREPRESENTATIVEOFFULL
CIRCLEAUTHORIZEDTOENTERINTOANAGREEMENT—
EXPRESSORIMPLIED—
WITHMEORANYAPPLICANTFOREMPLOYMENTFORASPECIFIEDPERIODOFTIMEUNLESSSUCHANAGREEMENTISINA
WRITTENCONTRACTSIGNEDBYTHEBOARDOFDIRECTORS.
IFHIRED,IAGREETOCONFORMTOTHERULESANDREGULATIONSOFFULL
CIRCLE,ANDIUNDERSTANDTHATFULL
CIRCLEHASCOMPLETEDISCRETIONTOMODIFYSUCHRULESANDREGULATIONS
ATANYTIME,EXCEPTTHATIT
WILLNOTMODIFYITSPOLICYOFEMPLOYMENTAT-WILL.

5. IauthorizeFull
Circleoritsagentsto
confirm
all
statementscontainedinthisapplicationand/orrésuméasitrelatestothepositionIamseekingtotheextentpermittedbyfederal,state,or
locallaw.Iagreetocompleteanyrequisiteauthorizationformsforthebackgroundinvestigationwhichmaybepermittedbyfederal,state
and/orlocallaw.Ifapplicable,Iwillreceive separatewrittennotificationregardingFull Circle’s intentto obtain“consumerreports.”
Iauthorizeandconsentto,withoutreservation,anypartyoragencycontactedbythisemployertofurnishtheabovementionedinformation.Iherebyrelease,discharge,andholdharmless,totheextentpermittedbyfederal,state,andlocallaw,anyparty
deliveringinformationtoFamilyForwardoritsdulyauthorizedrepresentativepursuanttothisauthorizationfromanyliability,claims,ch
arges,orcausesofactionwhichImayhaveasaresultofthedeliveryordisclosureoftheaboverequestedinformation.Iherebyreleasefro
mliabilityFull
Circle
Youth
and
Family
Services,
PLLC
anditsrepresentativeforseekingsuchinformationandallotherpersons,corporations,ororganizationsfurnishingsuchinformation.Fu
rther,ifh i r e d ,I authorizeFull
Circle
Youth
and
Family
Services,
PLLCtoprovidetruthfulinformationconcerningmyemploymenttofutureemployersandholdFamilyForward harmlessforproviding
suchinformation.
IfhiredbyFull
Circle,IunderstandthatIwillberequiredtoprovidegenuinedocumentationestablishingmyidentityandeligibilitytobelegallyemployed
intheUnitedStatesbyFull
Circle.IalsounderstandFull
CircleemploysonlyindividualswhoarelegallyeligibletoworkintheUnitedStates.
THISAPPLICATIONWILLBECONSIDEREDACTIVEFORAMAXIMUMOFSIXTY(60)DAYS.IFYOUWISHTOBECONSIDERED
FOREMPLOYMENTAFTERTHATTIME,YOUMUSTREAPPLY.
ICERTIFYTHATALLOFTHEINFORMATIONTHATIHAVEPROVIDEDONTHISAPPLICATIONISTRUE,ACCURATE,
ANDCOMPLETE.
DO NOT SIGNUNTIL YOUHAVEREADALLOF THEINFORMATIONCONTAINED INTHEAPPLICATION.
ApplicantSignature
Date
/
/
Iftheapplicant isaminor,the foregoingreleaseandconsentmustbesignedbytheapplicant’s parentor legalguardian.Signaturebythe
applicant’sparentor legalguardianconstitutesacknowledgementbytheapplicantandtheparentor legalguardianthatFull Circle Youth and
Family
Services,PLLCtotheextentpermittedbyfederal,state,andlocallaw,cantesttheapplicantforillegalorcontrolledsubstances,conductinspections
ofproperty withoutnotice,andcommunicatetestresultstoFull Circlepersonnelwhoneedtoknow,theapplicant, andtheapplicant’s
legalguardian.
Parent/LegalGuardian
Date
Date
*** For Office PersonnelOnly***
Date Received:
Reviewed by:
Witness

6. FormW-9(Rev.12-2011)
Page6