ࡱ> fe @\pCrossroads Managed Care Ba==>+N*8X@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1 Arial1 Arial1Arial1Arial1Arial1Symbol1Arial1. Times New Roman1.Times New Roman1 Arial1$Arial1Arial1.Times New Roman1Arial1Tahoma1Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)0."Yes";"Yes";"No""True";"True";"False""On";"On";"Off"mmmm\ d\,\ yyyy,'[<=9999999]###\-####;\(###\)\ ###\-#### "$"#,##0 dd\-mmm\-yy mm/dd/yyyy                + ) , *           h  h   x@) x ) x    X  `@) P    x@) x )  x@)  ` )  h )  x@@) x@) x  @)  h p p       "@ @  p ) x)  h )  h)  h@)  h) x)  h )  h  @) p)  h)   h) p ) p ) x  @)  @ X  H  H  H  H   H X  H P  H X |@) |@@) |@ ) x  ) p@) p @ )  x )  x )  x )  @)   )  "@ ) !X ! p  @) x@) p ) x@@) p@) 0 q @ P) p ) x @ ) p ) 0q @ xq@@  xq@@  0q@ x@)  0 x@) x@ ) 0 0  P) p@) x) p) P) p ) q@@ q@ q @ |@) x) p) x ) @@ @  @ x )  @ x@) xq@@ ) pq@ ) p q @ ) pq @ ) xq@@ )   x@  x@  x  xr@@ ) pr@ ) pr @ ) xr@@ ) p r @ ) p @ ) x@) p ) x@@) p@) p  @) x@ ) p ) pp ) xp@ ) pp ) pp ) xp@ )  @@  @   @  @  @   @  @@ @  @ x@@)  p@)  p@)  p)  pp ) x @)  p )  pp ) xq@ ) w@@ w@ w @  pp )  p @ )  p )  pp ) x@)  p @ )  @@  @   @  @@ "@ "p @ " @ " "p  pq@ )  pq @ )  p @)  pp@ )  pp@ )  p )  p )  p  ) pp ) p @ ) pp )  @@   @   p q @ )  @      p  @)  p@)  0@  0@  0 x  @) x ) !X #X  #X   X  X  pr@ )  pr @ )  p r @ )  @@   @  @@   @  @@  '@@  ' @  '@@  '@  ' @  '@@ w@ w @ x) w @ q@@ q @ x@) @@ @  @ pp @) ppq @ ) @@ @  @ @     q@@  q @  @   @  @@   @ !@@ !@ !  @  @@  @   @  @      @@  @ "@@ "@ "  @  p@ )  p ) x@@) #p@) #p@) #p) #p@ ) #p )  '@@  '@  ' @ p@) @@ @  @  @   @@ 0@ !@@ !@ ! @ x @ ) p ) x ) p ) x@@) p@) p  @) w@@ "'@@ "'@ "' @  '@@  '@  ' @ =x) = =x) p @ ) p ) p )  !x@ !p@ !p  x@@) p@) pp@ ) pp )  @@  @  @   @ x@@) p@) p)  @)  @ )  @   @  @      0@  0  `N6Employment Application8ZR 3  @@  WAPPLICATION FOR EMPLOYMENT Full Time Part Time TemporaryWeekendsEveningsNightsYesNo When could you start employment?When?Where?7 Have you ever applied for employment with our company?: Are you legally authorized to work in the United States? Home Phone: Street Address: Position(s) applied for: Name (Full - Last, First, MI): Business Phone:2 Have you previously been employed by our company? Date: City: State: Zip: Name of Company: From Month/Year: To Month/Year: Duties: Reason for Leaving: May we contact your supervisor?$ Title and Department of Supervisor: Name of Supervisor: Phone Number of Supervisor: High School or GED Address: Subjects Studied: Degree: College Graduate School Other Major GPA= PERSONAL INFORMATION (Complete all applicable information)" % GENERAL) References (Employment and/or Personal):Name:Address:If yes, please explain:9 Have you ever been convicted of a felony sexual offence?u If applying for clerical position, what business equipment can you operate? (For example: computers, copiers, etc.) Do you have stenographic skills?Typing skills? Words/Minute:N In what computer software programs are you proficient? Name of package(s):/ PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Date SignatureIn consideration of my employment, I agree to conform to the policies and procedures of the company. I understand that in accepting this application, the company is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time.I also understand that any offer of employment is conditioned on the completion of pre-employment tests and documentation. I will, upon request, sign all necessary consent forms.: Certificate of Licenses related to position applying for:!Crossroads' Turning Points, Inc. x Are you related to any current employee of CTP, CTP Foundation, CTP Advisory Board or CTP Governing Board of Directors?Diploma:!Will work (Check all that apply):& Do you have a valid driver's license? Driver's Licence Number:YN` EMPLOYMENT HISTORY (List below last three employers, starting with the most recent one first)/ Starting Pay: Final Pay:Next Previous Position: EDUCATION INFORMATION E-Mail:W Phone: Alt Phone:o Have you ever been convicted of, received a deferred sentence for, or pled no lo contendere to a felony crime?L \\If yes, when & where, and what is the disposition of the case (e.g. probation, parole, etc.)PNote: A conviction will not necessarily disqualify an applicant from employment. Have you been convicted of, received a deferred sentence for, or pled no lo contendere to any traffic violation in Colorado orG W' elsewhere within the past three years?d If yes, please explain (a conviction will not necessarily disqualify an applicant from employment):`I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application or omission of fact on either this application or during the pre-employment process will result in my application being rejected, or if I am hired, in my employment being terminated.Present or Last Position:Z' @(r)D)e**-+A-s01 2 @ $tASgx"  dMbP?_*+%EHE&LPage &P of &N&RCTP-H-0053 Application For Employment Rev 11-07-2008&333333?'?(?)q= ףp?M RICOH Aficio 1515 PCL 6 (IS) odXXLetter (8.5" x 11")RICOH Aficio 1515 PCL 6LPT1:   q  d''''ddo Default"dXX? ףp= ?cwU} } #} $} ^*@! 11 1  4  1311 11 11 *@  4 4 4] >* $#]E +J#ENF#FG 8 #GNH#HH F$GGGGGGGGGGGGGGG OAGGGGGGGGG: : ! "#HNGHIIIIIIIIIIIIIIIPQQQQQQQQQ55#GNHJKKKKKKKKKKKKKKKPQQQQQQQQQ99#H,GLMMMMMMMMMMMMMMMR5 ~5 ~5 ~5! 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