604 Walnut Street Green Cove Springs, FL

32043

Executive Director Al Rizer, Ph.D.

President

John Bowles

Vice-President Elizabeth Peeples

Secretary John Powers

Treasurer Greg Moorehead

Immediate Past President Ron Coleman

Board Members

Leslie Rickabaugh Tina Bullock

Theresa Crockett Rob Gaddy

Barbara Garner Elsbeth Geiger

Sylvia Kinnear

John Powers Michael White

Lynn Elliott Wendell Davis

Past President’s Advisory Panel Jerry Williams

Honorary Board Members Joan Bazley

Dorothy Ann Carlton Norma Elliott

Ex-Officio

Grady H. Williams, Jr., LL.M. Nancy E. Kemner, LL.M.

Phone 904-284-3134

Fax 904-284-0296

Web Address www.clayccoa.com

TO: All Prospective Employees

FROM: Al Rizer, Ph.D.

Executive Director

RE: Drug Testing National Background Screen Local Background Screen Abuse Registry

All prospective employees of the Council on Aging of Clay County must undergo a drug test, abuse registry check and background screening using a live scan fingerprint check. The Council on Aging’s client population is frail and vulnerable. There are occasions when it is necessary for an individual to begin their employment prior to the receipt of the above mentioned reports. If any drug report is returned positive, or if the reports from law enforcement or the abuse registry indicate convictions for crimes or involvement in abuse situations, the Council on Aging reserves the right to terminate employment immediately.

I, ________________________________________________understand that my employment with the Council on Aging may be subject to termination if my pre-employment drug test is positive or the abuse registry screening and/or background screening indicates a conviction for a crime or involvement in an abuse situation.

_______________________________________________

Signature

_______________________________________________ Date

A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (800) 435-7352 WITHIN THE STATE. THE WEBSITE IS www/freshfromflorida.com

REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. OUR REGISTRATION NUMBER IS CH290

Council on Aging of Clay County Application for Employment

Date of application: ______________

Name: ________________________________________________________________________ Last First MI Address: ______________________________________________________________________ Street City State Zip Telephone: ________________________ Social Security #: _____________________________ Position applied for: _______________________________ Date available: _________________

REFERRAL SOURCE ___ Advertisement ___ Employee ___ Relative ___Walk-In ___Other Have you ever been employed by the Council on Aging of Clay County before: ___ Yes ___ No Dates of previous employment with COA (if applicable): _______________________________ Do you have any relatives employed by the Council on Aging of Clay County? ___ Yes ___ No If yes, give name, relationship and department/location where they work: __________________ _____________________________________________________________________________ Are you currently employed? ___Yes ___No May we contact your present employer? ___Yes ___No

Only complete this section if you are applying for the position of Bus Driver: (Need Copy of Driver License)

1. Driver’s License #: ________________________ State: __________

2. Moving violations within the past three (3) years:

_______________________________________________________________________ Note: Failure to disclose traffic violations will be grounds for immediate dismissal. Your motor vehicle record will be checked by this agency and the insurance company.

3. Have you had any conviction (at any time) for DWI or DUI, reckless driving, vehicular manslaughter, or any conviction of operating any kind of motorized vehicle under the influence of alcohol or any illegal drug or controlled substance. Yes ____No____

4. Have you had your license suspended, cancelled, or revoked? Yes ___ No_____

EDUCATION High School: Name/Location Years Attended Graduation Date Subjects College: Name/Location Years Attended Graduation Date Subjects Trade/Business: Name/Location Years Attended Graduation Date Subjects Subjects of Special Study:

______________________________________________________________________________

______________________________________________________________________________

EMPLOYMENT HISTORY List the last four employers, starting with your present or most recent.

Begin/End Date Name & Address/Employer Position& Salary Reason for Leaving_ __________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

Military History: ______________________________________________________________

Branch of Service: ____________________________________________________________

Number of Years/Highest Rank: _________________________________________________

2 Clay County Council on Aging Employment Application

REFERENCES List (3) persons not related to you, whom you have known at least (1) year

Name Address Telephone Business Years Known ______________________________________________________________________________________________________________________________________________________________________________

PHYSICAL RECORD Do you have any physical disabilities that preclude you from performing the work for which you are applying? ___Yes ___No If yes, explain: ___________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Were you ever injured on the job? __Yes __No If yes, explain: __________________________ Have you any defect in: Hearing __Yes __No Vision __Yes __No Speech __Yes __No In case of emergency, please notify: ______________________________________________________________________________ Name Address Phone Relationship AUTHORIZATION I authorize investigation of all statements contained in this application, I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice. Signature: ______________________________________________ Printed Name: ___________________________________________ Date: __________________________________________________ The Council on Aging of Clay County is an EEO/AA/Title VI/Title IX/Section 504/ADA/ADEA institution in the provision of its employment programs and services. All qualified applicants will receive equal consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, marital status, sexual orientation, gender identity, age, physical or mental disability, genetic information, or covered veteran status.

3 Clay County Council on Aging Employment Application

604 Walnut Street

Green Cove Springs, FL 32043

LOCAL CRIMINAL BACKGROUND CHECK

I, _________________________________, authorize the Council on Aging of Clay County to request a local agency check and/or the State of Florida Department of Law. I understand that the Council on Aging of Clay County will be notified of any criminal charges against my record. I ( ___ Have) or ( ___ Have Not) been convicted of a felony. ______________________________________ Signature ____________________ Date Information needed for record check: Name: _____________________________ AKA: _____________________ Date of Birth: _____________ Sex: ____ Race: _______________________ Social Security No.: ____________________________________

A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY

CALLING TOLL-FREE (800) 435-7352 WITHIN THE STATE. THE WEBSITE IS www/freshfromflorida.com REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. OUR REGISTRATION NUMBER IS CH290

Executive Director Al Rizer, Ph.D.

President

John Bowles

Vice-President Elizabeth Peeples

Secretary John Powers

Treasurer Greg Moorehead

Immediate Past President Ron Coleman

Board Members

Leslie Rickabaugh Tina Bullock

Theresa Crockett Rob Gaddy

Barbara Garner Elsbeth Geiger

Sylvia Kinnear

John Powers Michael White

Lynn Elliott Wendell Davis

Past President’s Advisory Panel Jerry Williams

Honorary Board Members Joan Bazley

Dorothy Ann Carlton Norma Elliott

Ex-Officio

Grady H. Williams, Jr., LL.M. Nancy E. Kemner, LL.M.

Phone 904-284-3134

Fax 904-284-0296

Web Address www.clayccoa.com