Job Application: Health Support Coordinator (HSC)

Title: Health Support Coordinator (HSC)

Fields marked with an asterisk (*) must be filled out before submitting.

Thank you for applying for employment with TNC Community. Before completing the application, please review the following list of basic requirements. In order to be considered for employment, all applicants must meet the following basic criteria.

Basic Requirements for Employment. Please mark which of the following you currently meet. 1. At least 18 years of age
2. High School Diploma or GED
3. Valid Class E Driver’s License
 

Personal Information

Name *
Previously used names (alias, maiden names, nicknames, etc.)
Referred By:
Email Address *
 
Phone *
Alternate Phone *
Date of Birth (MM/DD/YYYY) *
 
Address *
City *
State or Province *
Zip or Postal Code *
 
Is this your permanent address * Yes
No
If no, what is your permanent address?

TNC Group Homes operate on standardized scheduling for our direct care positions. Our Individual Supported Living (ISL) locations operate on different schedules. Please select the following days, time and locations in which you are interested.

Work Days: First Choice *
Work Days: Second Choice *
 
Times: First Choice *
Times: Second Choice *
 
Locations: First Choice *
Locations: Second Choice
Locations: Third Choice

Employment Desired

Position Desired *
Salary Desired *
First Available Date *
 
Have you ever worked for TNC Community before? Yes
No
If yes, when? Please state your reason(s) for leaving

Background Information

Are you legally authorized to work in the U.S.? Yes
No
 
 
Have you ever been convicted of a crime? (A conviction will not necessarily result in the denial of employment.) *
If YES, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment
 
How many motor vehicle accidents have you been involved in during the past three years?
 
How many moving violations have you received in the past three years?

Education

High School: Name, Location
High School: Years Attended
High School: Graduated
 
College 1: Name, Location
College 1: Years Attended
College 1: Graduate
College 1: Subjects Studied
 
College 2: Name, Location
College 2: Years Attended
College 2: Graduate
College 2: Subjects Studied
 
Trade/Business/Tech School: Name, Location
Trade/Business/Tech School: Years Attended
Trade/Business/Tech School: Graduate
Trade/Business/Tech School: Subjects Studied

General Information (Include Dates & Certifications)

Subjects of Special Study/Resarch Work
Special Training
Special Skills
U.S. Military Service

Former Employers (Most recent First)

Employer 1: Name, Location
Employer 1: Dates of Employment
Employer 1: Salary
Employer 1: Position + Job Description
Employer 1: Reason for Leaving
Employer 1: Permission to Contact?
Employer 1: Contact Information
 
 
Employer 2: Name, Location
Employer 2: Dates of Employment
Employer 2: Salary
Employer 2: Position + Job Description
Employer 2: Reason for Leaving
Employer 2: Permission to Contact?
Employer 2: Contact Information
 
 
Employer 3: Name, Location
Employer 3: Dates of Employment
Employer 3: Salary
Employer 3: Position + Job Description
Employer 3: Reason for Leaving
Employer 3: Permission to Contact?
Employer 3: Contact Information
 
 
Employer 4: Name, Location
Employer: 4: Dates of Employment
Employer 4: Salary
Employer 4: Position + Job Description
Employer 4: Reason for Leaving
Employer 4: Permission to Contact?
Employer 4: Contact Information

References: Please give the names of three persons not related to you, whom you have known for at least one year.

Reference #1: Name, Contact Information, Business
Reference #1: Years Known
 
Reference #2: Name, Contact Information, Business
Reference #2: Years Known
 
Reference #3: Name, Contact Information, Business
Reference #3: Years Known
By clicking SUBMIT MY APPLICATION button below: * I certify that the facts contained in this application are true and complete to the best of my knowledge and understanding that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
This waiver does not permit the release of use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
 
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