Preliminary
Pre-Application Date:
Position Desired (Position No.):
County:
Macon
Overton
Putnam
Warren
White

How did you learn about Pacesetters?:
Newspaper
Radio
Friend/Relative
Walk-In
Employment Agency
Website
Other

Referred by?:

Applicant Information
Last Name:
First Name:
Middle Name:
SSN:
St Address:
Apt #:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Have you ever been convicted of a felony?: Yes No

Please explain:


In order to permit a check of your work and educational records, should we be aware
of any changes of name or assumed name that you previously used?: Yes No

Please list names and relevant dates:
Name/Date
Name/Date
Name/Date

Extra Requirements Some positions require that you work a flexible shift schedule with mandatory overtime
as needed.Will you work Overtime?: Yes No

Are there any days that you will not work? Please check.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

If yes, please explain:

Driver Information Do you have transportation to work?: Yes No
Do you have a valid TN Driver's License?: Yes No
DL Number:
Expiration Date:
Class:
Have you been licensed (not including permit)
for at least 3 years?: Yes No
Have you had any accidents
in the last 5 years?: Yes No

Friends or Relatives Do you have any friends or relatives who work at Pacesetters?: Yes No
Please list name(s) and relationship(s):
Name / Relationship:
Name / Relationship:
Name / Relationship:

Previous Employment Have you ever been employed with Pacesetters before?: Yes No
When were you employed?:

What was your name when you worked here?:
At which location were you previously employed?:
Macon
Overton
Putnam
Warren
White
Have you ever been dismissed or forced to resign from any employment?: Yes No
When, why and from where were you dismissed?:

Contact Information
In case of emergency, notify:
Contact Phone:
Address of Contact:
Contact State:
Zip:

Education
Name and Location
of School		 Course of Study No. Yrs.
Comp.		Did You
Graduate?		Degree or
Diploma
High School YesNo
College YesNo
Bus./Trade YesNo
Other YesNo

Professional Certification/Registration/Licensure
Do you currently have a certification
of license for a professional position? Yes No

If yes, please bring a copy with you to the interview.

Type of certification State or National Certification, Registration or License:
Registration
License
State
National
License No./Expiration Date:
Has your license ever been suspended or revoked? Yes No
If yes, please explain:

Military Military Have you ever served in a branch of the armed forces? Yes No
Which branch?
Describe any special training received in the Military:

Personal references (Must be 3 non-relatives with at least 1 having known you for at least 5 years Name: Occupation: Relationship: Yrs. Known: Day Phone: Evening Phone:
Name: Occupation: Relationship: Yrs. Known: Day Phone: Evening Phone:
Name: Occupation: Relationship: Yrs. Known: Day Phone: Evening Phone:

Employment
  • Please give accurate, complete full-time and part-time employment record.

  • Start with your present or most recent employer.

  • We must have a continuous account of employment/occupation for the past 5 years.

  • Incomplete information may result in your application not being considered.


Current/Most recent:
Company Name Telephone Address
Starting Pay Ending Pay
State job title and describe work Reason for leaving


Previous 1:
Company Name Telephone Address
Starting Pay Ending Pay
State job title and describe work Reason for leaving


Previous 2:
Company Name Telephone Address
Starting Pay Ending Pay
State job title and describe work Reason for leaving


Previous 3:
Company Name Telephone Address
Starting Pay Ending Pay
State job title and describe work Reason for leaving

Legal

Applicant's Statement

I certify that all answers given herein are true and complete to the best of my knowledge. I authorize the investigation of all matters contained in this application and hereby give PACESETTERS, Inc. (hereinafter referred to as PACESETTERS) permission to contact schools, previous employers, references and others and hereby release PACESETTERS from any liability as a result of such contact. I understand that misrepresentations, omissions of fact or incomplete information requested in this application may remove me from further consideration from employment. In addition, I understand that employees who are found to have misrepresented or omitted facts called for in this applicatin may be dismissed at any time without notice.

I understand that, if I am accepted for employmend, while PACESETTERS makes every effort to provide steady, continous work, we have no employment contracts, and PACESETTERS cannot guarantee the permanence of any position. Job tensure can be affected by any factors, including business/ economic conditions, changes in laws or employer policies, conformity to work rules, job performance, etc., or my decision to leave of my accord.

I understand that my employment with PACESETTERS is for no specific term and my be terminated by me or by PACESETTERS with or without notice or cause at any time. I further understand that no oral promise, PACESETTERS policy, custom, business practice or other procedure, implied or expressed, constitutes an employment contract or modification of the at-will employment relationship between PACESETTERS and me.

I understand that PACESETTERS personnel policies and guidelines are subject to change or modification by PACESETTERS solely at its discretion, without notice. I also understand that no supervisor or other official of PACESETTERS (except its Executive Director, in writing) has the authority to enter into any agreement with me or to make any agreement contrary to the foregoing.

I understand that PACESETTERS complies with the Americans with Disabilities Act of 1990, and that, during the interview process, I may be asked questions related to my ability to perfrom the essential job functions of the position for which I have applied.

I understand that, as a conditional offer of employment, I will be required to underfo a post-job-offer urinalysis drug screening. I aslo understand that PACESETTERS is a drug- and alcohol-free Agency and that I, if employed by PACESETTERS, may be subject to tests for drug/ alcohol use to reasonable suspicion and post-accident. Employment with PACESETTERS is contingent upon successful passing of these tests.

I understand also that if I am given a conditional offer of employment, I will be required to submit to and successfully pass a thorough background check completed in accordance with TCA 33-1-209. Background checks reveal misdemeanors and felonies (such as theft/robbery, worthless check writing, motor vehicle tickets/ accidents, drug/ alcohol convictions, sex crimes, voyeurism, arson and any criminal activity). All previous criminal activity must be reported to PACESETTERS. I understand that additional checks, including the Tennessee Elderly and Vulnerable Abuse Registry, the Tennessee Sexual Offender Registry and the DMRS Perpetrator List, and performed.

This applicatin will remain active for ninety (90) days. Any applicant wishing to be considered for employment beyond ninety (90) days must reapply.

PACESETTERS, Inc is an Equal Opportunity Employer and makes employment decisions based solely upon applicant qualifications, without regard to race, age, sex, religion, national origin, handicap, or marital status. PACESETTERS, Inc is a United Way Agency.

Checking the box to the right is considered the same as signing an application I accept the terms