Application

    ​Work Experience

    ​List your 3 most recent employers 

    Education

    ​Professional References

    ​Please provide at least 3 professional references and please do not include relatives  

    ​Prescreen Questionnaire

    Availability

    ​Additional Information 

    By signing below: I declare that all the information provided on my application for employment with Building Bridges to Independence, LLC is accurate, true and can be verified if necessary. I understand that any false statements or deliberate omissions on this application may be grounds for disqualification from employment or, if discovered after employment begins, could result in discipline up to and including my termination of employment. 
    ​I hereby authorize Building Bridges to Independence, LLC to verify the information provided on the employment application. The information subject to verification includes but is not limited to; former employment (dates of employment, responsibilities, schedule, supervising experience, quality of work, strengths and areas for improvement, communication, reason for leaving and eligibility for rehire), education, existence on registry and degree. 

    ​Criminal History Records Check Authorization 

    I hereby authorize Building Bridges to Independence, LLC to request a criminal history records check, and I further authorize the State Police to release information relative to the existence or non-existence of any criminal record which it may have concerning me to the requestor solely to determine my suitability for employment or continued employment. I further authorize any agency which maintains records relating to me to provide the same request. I certify that the State Police and any agency who furnishes this information shall be held harmless from all liability which may be incurred because of releasing such information. I further acknowledge that Building Bridges to Independence, LLC shall not be liable for the failure to hire or retain an applicant or employee who has been convicted of committing or attempting to commit crime which has not been expunged. I understand that the information requested below regarding date of birth, gender, race/ethnicity is for the sole purpose of identification and the gathering of the above-mentioned information about me accurately and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my social security number is ​required by law. A facsimile or photographic copy of this authorization will be as valid as the original. 
    ​I declare that all information provided on this document is true and accurate. I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment or if discovered after employment begins, could result in discipline up to termination of employment. I understand that fees for the criminal history records check and fingerprints are not refundable

    Previous Three (3) Years Addresses  

    Work Addresses:
    ​Home Addresses:

Building Bridges To Independence LLC

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Phone: 812-767-3739
Email: [email protected]
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