Form Mo 886 1315 – Fill Out and Use This PDF

Your Potential. Our Support.

INSTRUCTIONS: Please type or print in ink.Attach additional sheets if necessary. Resumes are not accepted in lieu of a completed application.

PERSONAL INFORMATION

naMe (last, first, Middle, suffix)

have you ever been known by another naMe?

yes      no      if yes, please list

hoMe address (street, city, state, zip code)

list relatives currently working for the department of social services (i.e. spouse, parents, children, grandparents, grandchildren, siblings, first cousins, in-laws, aunts, uncles, nephews and nieces – include all blood, step and foster relationships).

EDUCATION

are you a high school graduate or do you have an equivalency (ged) certificate?    yes    no

List College, University, Vocational School, Others (Attach Transcripts)

if applicable to your profession, list association or licensing authority and certification, registration or license nuMber.

have you ever been terMinated froM eMployMent or asked to resign by an eMployer? IF YES, please provide coMpany naMes and details

yes      no

Describe in detail all positions that you have had during the last ten (10) years, starting with most recent employment. If more than one position or classification has been held with a given organization, list each position or classification as a separate period of employment. Attach extra sheets if necessary.

telephone

naMe of supervisor

Mo 886-1315 (6-13)

CONDITIONS OF EMPLOYMENT

1.you may be required to work outside of your normal work schedule, including early mornings, nights or weekends. will you accept this condition?  yes      no

2.you may be required to travel. will you accept this condition?  yes      no

3.compensatory time is normally granted in lieu of overtime payment in cash. will you accept this condition?  yes      no

4.you will be required to direct deposit your paycheck or receive a paycard in lieu of a paper check. will you accept this condition? yes      no

5.failure to file all Missouri state income tax returns and pay all state income taxes owed may result in dismissal from employment. will you accept this condition?

yes      no

6.in support of the u.s. Military selective serviceact, the state of Missouri requires individuals employed by the state be registered with the selective serviceadministration. if hired by dss and if you are a male, 18-26 years of age, will you meet this requirement?  yes      no      n/a

7.are you currently under charges for any criminal offense?  yes      no (if yes, this does not necessarily exclude you from consideration for employment.) if yes, provide the following:

circuMstances (identify charges)

8. for any criminal acts, have you ever been convicted, pled guilty or nolo contendere, or received a suspended imposition of sentence (regardless of whether incarceration actually occurred)? yes      no (if yes, this does not necessarily exclude you from consideration for employment.) provide a full explanation for each incident, including misdemeanors or felonies, and indicate whether you are currently on or have been on supervised or unsupervised probation.

circuMstances (identify charges)

9.have you ever been involved as a perpetrator in any child abuse or elderly abuse which was substantiated or determined probable cause or reason to suspect and documented by a state agency, regardless of whether proven in court and whether a criminal conviction of any kind occurred?  yes      no if yes, complete the next two lines.

circuMstances (identify charges)

10.dss conducts pre-employment background checks on final candidates as listed below (paid by the agency with the exception of the cost associated with providing a driver’s

record for applicants with a confidential or out-of-state driver’s license). all offers of employment are conditional on results of background checks. background check results will not be released to you by dss. will you accept this condition?  yes      no

Background checks include but may not be limited to: employment history and references; professional certifications and educational requirements; fingerprint checks for open and closed federal and state criminal records; sex offender registry; child abuse/neglect records; child care facility and foster parent licensing records; department of Mental health employee disqualification registry; department of health and senior services disqualification list; family care safety registry; central registry for adult neglect/exploitation; claims accounting restitution system for debts owed to the state for benefits inappropriately received; and driver’s license status.

Background check results which may cause the withdrawal of a conditional employment offer, rejection of an applicant, dismissal of an employee or rejection of a volunteer, etc. include but are not limited to those which:

•display the propensity to harm a client or resident (e.g., but not limited to if an individual has been involved as a perpetrator in any child or elderly abuse which was substantiated or determined by a preponderance of the evidence, probable cause or reason to suspect and documented by a state agency, regardless of whether proven in court or whether a criminal conviction of any kind or occurred; and if an individual engaged in sexual abuse or harassment of an inmate, detainee, client or resident in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution).

•demonstrate that an individual is unsuitable for employment or service including criminal acts for which they are under current charge or have been convicted, found guilty, pled guilty or no contest or nolo contendere, or received a suspended imposition of sentence (regardless of whether incarceration actually occurred);

•negatively affects public confidence in dss, its staff and services;

•violate the provisions and regulations of dss programs (e.g., illegally receiving public assistance payments);

•result in the individual being unable to obtain and/or maintain a valid driver’s license when required for the position; or

•demonstrate an unsatisfactory employment background.

READ VERY CAREFULLY BEFORE SIGNING

i certify that information given by me is true and complete to the best of my knowledge and belief. i understand that should an investigation at any time disclose any such misrepresentation, falsification, or concealment as to a material fact, it will be sufficient grounds for rejection of my application and/or removal from employment. i authorize the department of social services (dss) to investigate, obtain and compile information concerning my employment history; to obtain a copy of my college transcript(s); and to conduct a pre-employment background check and annual record review of myself, including information pertaining to any report of child or adult abuse or neglect revealed by an examination of government abuse/neglect records and/or information related to any convictions for criminal acts and other checks as listed above or deemed appropriate. i release dss from any legal liability that may result from these investigations. i waive all provisions of law forbidding colleges or universities which i attended, or past employers, from disclosing any information which they acquired relative to my employment. i consent that via a copy of this application form, they may disclose such information to dss. i understand that any offer of employment is conditional upon results of background checks and upon proof of legal authorization to work in the united states as required by the immigration reform and controlact. i hereby waive any rights to review any information obtained by dss as a result of background checks.

Mo 886-1315 (6-13)