Sertoma Center, Inc.

Employment Application

Thank you for your interest in our Company! This application is not an employment contract, but is intended to evaluate suitability for employment. It is our policy to provide equal employment to all qualified persons without discrimination on the basis of age, race, sex, color, religion, marital status, national origin, citizenship, disability, veteran status, or any other status protected under applicable local, state and federal law. It is also our policy to have the option of conducting a pre-employment interview, verifying references, and obtaining a consumer report before a job offer is made. Once a job offer is made, employment may be contingent upon successful completion of a medical examination and/or a drug screen test. All applicants are required to complete an application – even if a resume is attached. Thank you for your cooperation!

We Drug Test
We Maintain a Smoke-Free Workplace

Name and Address

First Name:  Middle:   Last: 

Street Address:   

Appartment/Unit #: 

City:  State:  Zip:   

Contact Info

Primary Phone Number:   Email Address: 

Secondary Phone Number:    Best time to contact: 


Did You Complete High School?

What did you graduate with?

Name of High School:   

City:     State:   


Have you attended College?

Name of College:   

City:     State:   

Prior Employment

Have you ever been employed by Sertoma Center?

Job Title:     From Date:     To Date:   

Have you ever been discharged or requested to resign from any job?



We are interested to know how you found us. Please tell us your source below:

Please name the person or place who referred you if you chose “Employee” or “Other”:   

Additional Information

Date Available to Start:   

Salary or Wage Expected?   

Please List any additional information you feel may be helpful to us in considering your application.   


Work Preferences (check all that you are interested in):

What shift schedule(s) are you looking for?

Please indicate which days you are available for work:

Are you willing to work overtime?

Are you on layoff and subject to recall?

Critical Info

Are you willing to clean toilets?

Are you willing to change individuals’ soiled clothing?

Are you willing to bathe a soiled individual?

Are you willing to prepare every type food requested?

Are you willing to cook balanced meals?

Are you willing to clean the kitchen and the oven?

Are you willing to take Persons Served to church?

Are you willing to help individual(s) work on goals?

Are you willing to take Persons Served out for recreation?

Are you willing to mop the floors?

Have you had a DUI conviction in the last 10 years?

Have you had a reckless driving conviction in the past 10 years?

Are you on any abuse registry?

Can you pass a drug test at any time?

Have you had 2 or more moving traffic violations in the last 3 years?

Have you ever had a felony conviction?

Have you had a misdemeanor conviction in the last 10 years?

EEO Information

Please identify your gender

Please identify your ethnicity

Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.)

Which of the following best describes your ethnicity?

This company is an Equal Opportunity/Affirmative Action employer and subject to certain reporting and affirmative action requirements. The information required on this page is requested only so that we may meet our Equal Opportunity/Affirmative Action obligations. Your completion of this form is purely voluntary and will not, in any way, affect your consideration for employment. Any information you provide on this page will be stored separately from your job application.

Voluntary Invitation to Self-Identify – Protected Veterans

As a government contractor, Sertoma Center is subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans.

Click Here to review the veteran classification definitions

If you believe you belong to any of the categories of protected veterans listed in the document above, please indicate by checking the appropriate answer below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Please identify your Veteran Status below:

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

This employer has adopted an affirmative action program to comply with its obligations under VEVRAA. The company is committed to a policy of equal employment opportunity for all protected veterans and to employing and advancing protected veterans in employment. This policy applies to all personnel actions, including selection and hiring, transfers, training, promotions, compensation, employee benefits, and terminations.

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability (previously called mental retardation)

Please check one of the boxes below:

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accomodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

iSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 mintues to complete.

Reference Information

Do any of your relatives or friends work here?

If yes, please name them and state your relationship:   

Please list references that you have known for at least 5 years. Do not list relatives or former employers.

Name:    Email:     Phone:   

Name:    Email:     Phone:   

Name:    Email:     Phone:   

Work History

Company:     Supervisor:   

Phone:    Job Title: 

Salary/Wage:    Dates Employed: 

Description of Job Duties: 

Reason for Leaving:   

Company:   Supervisor: 

Phone:    Job Title:   

Salary/Wage:    Dates Employed: 

Description of Job Duties: 

Reason for Leaving:   

Company:   Supervisor:   

Phone:    Job Title:   

Salary/Wage:    Dates Employed: 

Description of Job Duties: 

Reason for Leaving:   


Company:   Supervisor:   

Phone:   Job Title:  

Salary/Wage:   Dates Employed: 


Description of Job Duties:   

Reason for leaving:  

Military Information

Were you in the U.S. Armed Forced?


What branch of the U.S. Armed Forces did you serve in?

List any special skills or training that you received   

Criminal History Information

Before responding to the question below read the following statements:
Please do not answer “yes” or provide any information about convictions that have been erased, expunged, sealed, pardoned, set aside, vacated, annulled or otherwise eradicated by a court. Note: A conviction will not necessarily disqualify you for the position for which you have applied or act as an automatic bar to employment unless applicable law requires such action. Instead, the decision about your employment will depend on the job, time, nature and seriousness of the conviction and related rehabilitation.

Have you ever been convicted, plead guilty, or plead ‘no contest’ to a crime?

Date of Conviction:     What State?   

Please State the crime committed and disposition/sentencing of this offence:

Bond History

Have you ever been bonded

Have you ever been refused a bond?

If “Yes” to either of above, please state reason and date:   

Have you ever held a position of trust (handling money or confidential material)?

Driving Information

Due to insuance regulations, all positions at Sertoma Center require a VALID TENNESSEE Drivers License with a good driving record. ANY applicant considereed for employment will have his/her driver’s license checked by the Department of Motor Vehicles. This is to provide Sertoma Center information regarding the status of the license(i.e., valid, suspended, etc.), and a list of violations and accidents.

If you have had any of the following, in the last three (3) years, this makes you an unacceptable driver:

  • DWI – Drugs or Alcohol
  • Hit and Run
  • Failure to Report an Accident
  • Negligent Homicide using a motor vehicle
  • Driving while license is suspended or revoked
  • Using Motor vehicle for commission of felony
  • Grand Theft
  • Permitting unlicensed person to drive
  • Reckless driving
  • Speed Contest
  • Any combination of accidents (regardless of fault) and moving violations two (2) or more
  • Anyone licensed less than three (3) years regardless of age

Any driver with a past history (over 3 years old) with more than one of these convictions could be considered unacceptable unlesss violation dates are eight years old or more.

Do you have a valid Drivers License?

What is your Drivers License Number and state of issue?

DL#:  State:  Expiration:

Have you had any accidents or moving traffic violations (not including parking tickets) in the past three (3) years – regardless of fault?

Please list ALL accidents and/or moving traffice violations (not parking tickets) that you have had in the past three years – regardless of fault.

Employment Inquiry Release

The following is for identification purposes only to perform a background check and will not be used for any other purpose.

Date of Birth:   Social Security Number:   

Please list any nicknames or previous names under which you received your GED, High School Diploma or other academic credentials:

I certify and affirm that, to the best of my knowledge and belief:

If you HAVE, please explain:



To protect the health and safety of our employees and persons served, to maintain a productive work force, and to preserve the Center’s reputation, we strictly enforce rules against the use, possession, and sale of alcohol and/or drugs. Accordingly, all applicants offered employment with the Center will be required to submit to drug and alcohol testing as part of a pre-employment screening process. If test results are positive or present evidence of possible abuse, the applicant is ineligible for employment.

I hereby consent and agree to give a specimen of my urine/blood to a qualified laboratory or any medical person designated by Sertoma Center, Inc. This specimen shall be used to detect the presence of drugs, alcohol or medications in my body. I further consent and agree that upon request by Sertoma Center, Inc., the laboratory results of any test performed on such specimen shall be furnished to Sertoma Center’s Human Resources Manager. I understand that the results of tests performed will be held in strict confidence. My signature below acknowledges that I have read and understand the foregoing statement and that this consent was freely and knowingly given.


Due to the implementation of Senate Bill 913, Sertoma Center, Inc., is required to conduct criminal background checks on persons employed to work with or having contact with persons with developmental disabilities either on a full or part-time basis.

Should you be hired by Sertoma Center, Inc., you will be required to submit a fingerprint sample within (10) days of your employment date. The fingerprint cards are used for criminal background check conducted by the Tennessee bureau of investigation and the federal bureau of investigation.

You must also list any prior convictions by any local, state, federal or military court of any felony or any other conviction involving sexual crimes, including but not limited to rape, sexual assault, sexual battery, exhibitionism, voyeurism, or an attempt to commit any of such sexual crimes; homicide or attempted homicide; felonious assault or attempted felonious assault; unlawful breaking or entering; robbery; burglary; theft; or arson. If you are required to register or have registered with the registry of sexual offenders, you should also disclose this information.

I have read the above statement and certify that the information provided by me is true in all aspects. I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge.


I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Sertoma and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Sertoma unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that Sertoma retains the same right.

I agree to submit to a physical examination whenever requested, and I understand my becoming employed and/or my continued employment are subject to my successfully passing any physical examination in accordance with company policies and procedures.

I understand that if employed, policies and rules which are issued are not conditions of employment and that the employer may revise policies or procedures, in whole or in part at any time.

I understand that this application will be kept on file for one (1) year from the date completed, after which time I would have to reapply in accordance with company procedures.


Sertoma Center, Incorporated (”Sertoma Center”), when considering your application for employment, when making a decision whether to offer you employment, when deciding whether to continue your employment (if you are hired), and when making other employment related decisions directly affecting you, may wish to obtain and use a “consumer report” from a “consumer reporting agency”. These terms are defined in the Fair Credit Reporting Act (“FCRA”), which applies to you. As an applicant for employment or employee of Sertoma Center, you are a “consumer” with rights under the FCRA.

A “consumer reporting agency” is a person or business which, for monetary fees, dues or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing “consumer reports” to others, such as Sertoma Center.

A “consumer report” is any written, oral or other communication of any information by a “consumer reporting agency” bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living which is used or collected for the purpose of serving as a factor in establishing the consumer’s eligibility for employment purposes.

If Sertoma Center obtains a “consumer report” about you, and if Sertoma Center considers any information tin the “consumer report” when making an employment related decision that directly and adversely affects you, you will be provided with a copy of the “consumer report” before the decision is finalized. You also may contact the Federal Trade Commission about your rights under the FCRA as a “consumer” with regard to ”consumer reports” and “consumer reporting agencies” .

By signing below, I certify that the information given by me in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge.

I authorized the use of any information in this application to verify my statements, and I authorize the past employers, doctors, all references, and any other persons to answer all questions asked concerning my ability, character, reputation and previous employment records. I release all such persons from any liability or damages on account of having furnished such information.

I agree to the above consents for Sertoma to perform Drug Testing, Background Checks, Drivers’ Information Checks, and Credit Reports on me as part of the application process and throughout my employment if I am hired.

Finally, I understand that I must treat any information I discover about the persons supported by Sertoma Center strictly confidentially; this includes information discovered during the interview process and during my employment. I cannot reveal the name, address, personal health information or any other information about any of the individuals or employees of Sertoma Center.


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Sertoma Center, Inc.
Signature Certificate
Document name: Employment Application
Unique Document ID: e7336692a2f850a719bc366d6f3c0e8dc4e87fcd
Timestamp Audit
2017-05-13 15:34:32 EDTEmployment Application Uploaded by HR Department - IP,