Employment Application CASA LA Step 1 of 7 14% CONFIDENTIAL DOCUMENT MANAGEMENTEmployment applications contain confidential inforrmation. Managers and Supervisors understand the importance of controlling access to applications in their care and the sensitive and confidential nature of the information contained in them. Every candidate and new employee is required to complete an application. We do not provide copies of candidates’ applications to othe companies or colleagues outside of our company.Application for Employment - CASA of Los AngelesCASA of Los Angeles is committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of race, color, religion, creed, national origin or ancestry, sex, gender, gender identity and expression, sexual orientation, age, physical or mental disability, medical condition, military status, uniform service member status, genetic information, marital status, pregnancy, driver’s license, or any other legally recognized protection basis under federal, state, or local laws, regulations or ordinances. The information collected by this application is solely to determine suitability for employment, verify identity and maintain employment statistics on applicants. Every candidate and new employee is required to complete an application. We do not provide copies of candidates’ applications to other companies or colleagues outside of our company. Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the way things are normally done which will ensure an equal employment opportunity without imposing undue hardship on CASA of Los Angeles. Additionally, please inform the company’s personnel representative if you need assistance completing any forms or to otherwise participate in the application process.Position Desired*Status*Full-TimePart-TimeDate Available to Work* APPLICANT INFORMATIONName* First Middle Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Number*Alternate ContactE-mail Address* Have you ever worked for CASA of Los Angeles?*YesNoplease give dates of employment and position title:*Have you ever filed an Application for Employment with CASA of Los Angeles?*YesNoplease give date:*For the purpose of verifying information on this application, have you ever worked or attended school under a different name at any of the organizations you have listed?*YesNoplease provide other names and explain:*Have you ever been terminated or asked to resign from any job?*YesNoplease explain the circumstances:*If hired, can you furnish proof that you are over 18 years of age?*YesNoDo you have reliable transportation to and from work?*YesNoAre you able to perform the essential functions of the positions for which you are applying, either with or without reasonable accommodation?*YesNoAre you bound by provisions of a noncompete, proprietary, or confidentiality agreement?*YesNofor how long?*Is there anything you wish to avoid in a new job?*YesNoplease explain:* EMPLOYMENT HISTORYPlease list the names of your present or previous employers in chronological order with present or last employer listed first . If selfemployed, give firm name and supply business references. Add additional page(s) if necessary.Employment History*Previous Employer Name:AddressPhone NumberMay we contact this employer? If No, please explain:Job Title or PositionDate Employment BeganDate Employment EndedJob ResponsibilitiesSupervisor’s Name and TitleSupervisor’s Phone Number and E-mailReason for Leaving Click the + button to add additional rows EDUCATIONAL BACKGROUNDHigh School, College or Vocational School, Advanced Degree, Other*Name and Address of InstitutionCourse of Study/Specialized Training or SkillsYears CompletedDiploma or Degree Obtained Click the + button to add additional rows PERSONAL REFERENCESPlease list persons who know you well who are not previous employers or relatives.*NameAddressOccupationTelephone Number# Years KnownE-mail Address Click the + button to add additional rows OTHER SKILLSPlease indicate any actual experience, special training and qualifications you may have that you believe to be relevant to the position for which you are applying. APPLICANT’S STATEMENT AND AGREEMENTIn the event of my employment with CASA of Los Angeles, I will comply with all rules and regulations of CASA of Los Angeles (“Employer”). Conditions of Hire: I understand that Employer reserves the right to require me to submit to a test for the presence of alcohol or drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent on passing of a physical examination and a test for the presence of alcohol or drugs in my system, performed by a doctor selected by Employer. Further, I understand that at any time after I am hired, Employer may require me to submit to a physical examination and an alcohol and drug test, to the extent permitted by law. I consent to the disclosure of the results of any physical examination and related tests to Employer. I also understand that I may be required to take other tests such as personality and honesty tests, prior to and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my employment may be terminated. I understand that bonding may be a condition of hire. If it is, I will be so advised either before or after hiring and a bond application will have to be completed. I understand employment with CASA of Los Angeles is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States. Authorization for Background Verification: I understand that Employer may contact my previous employers and I authorize those employers to disclose to Employer all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to Employer, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I authorize the persons named herein as personal references to provide Employer with any pertinent information they may have regarding me. Statement of Full Disclosure: I hereby state that all the information I provided on this application or any other documents completed in connection with my employment application, and in any interview are true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed by Employer and any such information is later found to be false or incomplete in any respect, I may be dismissed. At-Will Employment: If hired, I agree as follows: My employment and compensation is terminable At-Will, is for no definite period, and my employment and compensation may be terminated by either the Employer or me at any time and for any reason whatsoever, with or without good cause. This is the entire agreement between the Employer and me regarding dispute resolution, the length of my employment, and the reasons for termination of employment, and this agreement supersedes any and all prior agreements regarding these issues. It is further agreed and understood that any agreement contrary to the foregoing must be entered into, in writing, by the President of the Company. No supervisor or representative of the Employer, other than its President, has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the foregoing. Oral representations made before or after I am hired do not alter this Agreement. Introductory Period: If employed, I may be subject to an Introductory Period at the beginning of my employment in order that both the Employer and I evaluate my suitability for the position hired. The Introductory Period may be extended or be reimposed at any point in my employment. The existence of the Introductory Period does not alter, amend or remove the Employer’s At-Will employment policy. Nepotism Policy: Relatives, roommates, and romantic relations of current employees of CASA of Los Angeles may not work in a direct reporting relationship with such current employees, excluding relatives of persons with an ownership interest in CASA of Los Angeles. If you receive a conditional offer of employment, you may be asked to identify any relative, roommate, or romantic relation who is a current employee of CASA of Los Angeles. For purposes of this policy, “relative” is defined as any person who is related by blood or marriage, or whose relationship with the employee is similar to that of people who are related by blood or marriage; “roommate” is defined as any person who resides with the employee, regardless of affiliation; and “romantic relation” is defined as any person who is engaged in a relationship of a romantic nature with the employee. Arbitration: I further agree and acknowledge that the Employer and I will utilize binding arbitration to resolve all disputes that may arise out of the employment or pre-employment context. Both the Company and I agree that any claim, dispute, and/or controversy that I may have against the Employer (or its owners, directors, officers, managers, employees, agents, and parties affiliated with its employee benefit and health plans) or that the Employer may have against me, arising from, related to, or having any relationship or connection whatsoever with my seeking employment with, employment by, or other association with the Employer shall be submitted to and determined exclusively by binding arbitration under the Federal Arbitration Act, in conformity with the procedures of the California Arbitration Act (Cal. Code Civ. Proc. Section 1280 et seq., including section 1283.05 and all of the Act’s other mandatory and permissive rights to discovery). Included within the scope of this Agreement are all disputes, whether based on tort, contract, statute (including, but not limited to, any claims of discrimination and harassment, whether they be based on the California Fair Employment and Housing Act, Title VII of the Civil Rights Act of 1964, as amended, or any other state or federal law or regulation), equitable law, or otherwise, with exception of claims arising under the National Labor Relations Act which are brought before the National Labor Relations Board, claims for medical and disability benefits under the California Workers’ Compensation Act, Employment Development Department claims, or as may otherwise be required by state or federal law. However, nothing herein shall prevent me from filing and pursuing proceedings before the California Department of Fair Employment and Housing, or the United States Equal Employment Opportunity Commission (although if I choose to pursue a claim following the exhaustion of such administrative remedies, that claim would be subject to the provisions of this Agreement). In addition to any other requirements imposed by law, the arbitrator selected shall be a retired California Superior Court Judge, or otherwise qualified individual to whom the parties mutually agree, and shall be subject to disqualification on the same grounds as would apply to a judge of such court. All rules of pleading (including the right of demurrer), all rules of evidence, all rights to resolution of the dispute by means of motions for summary judgment, judgment on the pleadings, and judgment under Code of Civil Procedure Section 631.8 shall apply and be observed. Resolution of the dispute shall be based solely upon the law governing the claims and defenses pleaded, and the arbitrator may not invoke any basis (including but not limited to, motions of "just cause") other than such controlling law. The arbitrator shall have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator, which immunity supplements any other existing immunity. Likewise, all communications during or in connection with the arbitration proceedings are privileged in accordance with Cal. Civil Code Section 47(b). As reasonably required to allow full use and benefit of this agreement's modifications to the Act’s procedures, the arbitrator shall extend the times set by the Act for the giving of notices and setting of hearings. Awards shall include the arbitrator's written reasoned opinion. Any dispute concerning the validity, enforceability, scope or interpretation of this Agreement, or concerning the arbitrability of a particular claim, shall be resolved by a court of law of competent jurisdiction. I understand and agree to this binding arbitration provision, and I and the Company both give up our rights to trial by jury of any claim I or the Company may have against each other. Severability: If any term or provision, or portion of this Agreement is declared void or unenforceable it shall be severed and the remainder of this Agreement shall be enforceable. IF YOU HAVE ANY QUESTIONS REGARDING THESE STATEMENTS, PLEASE ASK AN EMPLOYER REPRESENTATIVE BEFORE SIGNING. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENTS AND AGREEMENT. I hereby acknowledge that I have read and understand the above statements and agree to the same.Signature
