Once you have read this page, please remove it from the application and keep for your personal reference.

WELCOME TO

NATIONAL CENTER ON INSTITUTIONS AND ALTERNATIVES (NCIA) As you consider a career with NCIA and to gain a better

understanding of our agency, please take few minutes to read the following information.

Once you have read this page, please remove it from the application and keep for your personal reference.

Name: ________________________________________________

Position Applied for: _____________________________________

Date of Application: _________________________________________

We are currently pre-screening all applications in the order in which they are received. Due to the volume of applications being received, this process may take 2-4 weeks. Candidates will be

contacted as soon as possible.

It is the mission of NCIA to help create a society in which all persons who come into contact with the human service or correctional systems will be provided an environment of individual care, concern and treatment.

NCIA is dedicated to developing quality programs and professional services that advocate timely intervention and unconditional care.

NCIA is an equal employment opportunity employer. Therefore, hiring and employment decisions at NCIA will be based on merit, qualifications, and abilities. NCIA does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law.

NCIA will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship. This policy and practice governs all aspects of employment, including selection, job assignment, promotion, compensation, discipline, termination, and access to benefits and staff training and development.

Employment with NCIA is voluntarily entered into, and the employee is free to resign at will at any time, with or without cause. Similarly, NCIA may terminate the employment relationship at will at any time, with our without cause, so long as there is no violations of applicable federal or state law. An offer of employment with NCIA is not intended to create a contract, nor is it to be construed to constitute contractual obligations of any kind or a contract of employment between NCIA and any of its employees.

NCIA’s Substance Abuse policy promotes our desire to provide a drug-free, healthful, and safe workplace.

Therefore, while on NCIA premises and while conducting business-related activities off NCIA premises, no

employee may use, possess, distribute, sell or be under the influence of alcohol or illegal drugs. Accordingly,

NCIA will maintain pre-employment screening practices designed to prevent hiring individuals who are current

Individuals who appear to be unfit for duty may be subject to a medical evaluation, which may include drug or alcohol screening. Refusal to comply with fitness-for-duty evaluation may result in disciplinary action up to and including termination of employment.

To ensure that individuals who join NCIA are well qualified and have a strong potential to be productive and successful, it is the policy of NCIA to conduct a criminal background check on each new employee. Due to regulations that govern the licenses of the programs that we operate, certain criminal background offenses and/or the time frame of some offenses may preclude an applicant from being considered for some positions at NCIA. Therefore, please provide NCIA with a complete and accurate criminal background history.

NCIA will also check employment and personal references, and educational background of all applicants being considered for employment. Please be sure to give complete name, address, and phone numbers of past and present employers, educational institutions, and personal references. Additionally, if an employment offer is made, you will be required to submit educational documentation on the day you complete your new hire paperwork.

A condition of initial and continued employment for NCIA direct care positions is the completion of, and required renewal of the Certified Mediation Technician (CMT) certification. Initially this requires completion of our 20 hour CMT course and a Maryland Board of Nursing (MBON) application, documentation of any and all criminal background history, presentation of a 2” X 2” passport photo and an application fee of $20. Renewal requirements include providing MBON with any change of address since the initial application, completion of a 4 hour recertification course, completion of the renewal application and a renewal fee of $30.

If an employment offer is made, you will also be required, as a condition of employment, to complete the Employment Eligibility Verification Form, I-9, and present documentation establishing identity and employment eligibility on the day that you complete your new hire paperwork. (A copy of the accepted documentation to fulfill this obligation can be obtained by contacting the Employment Specialist.)

NCIA intends to provide a work environment that is pleasant, healthful, comfortable and free from

intimidation, hostility, or other offenses, which might interfere with work performance. Sexual harassment and other types of harassment are against the law and they affect employee morale and interfere with our

performance. Therefore, sexual harassment and any other unlawful harassment will not be tolerated.

To help ensure that employees are able to perform their duties safely, medical examinations will be required of all direct care employees or any position that requires an employee to come in close contact with the

individuals we support on a regular basis. After an offer has been made to an applicant entering a position of direct care, a medical examination will be performed at the employee’s expense. The new employee will be required to present a doctor’s certification that they are free from TB, Hepatitis B, and any other

communicable diseases within 7 business days of their hire date, unless program regulations indicate differently. Direct care staff will be required to present an annual certification as a condition of continuing employment.

THANK YOU FOR YOUR INTEREST IN NCIA CAREER OPPORTUNITIES.

NATIONAL CENTER ON INSTITUTIONS & ALTERNATIVES 7205 Rutherford Road

Baltimore, Maryland 21244 Phone: 443-780-1300

Fax: 410-597-9656

Website: www.ncianet.org

NATIONAL CENTER ON INSTITUTIONS & ALTERNATIVES 7205 Rutherford Road, Baltimore, Maryland 21244

Phone: 443-780-1300 APPLICATION FOR EMPLOYMENT ACKNOWLEDGEMENT

By my initials I acknowledge that I have read and understand the statements and polices described in the (Welcome document – need to name it).

Today’s Date: Position and/or Program Applying for:

PERSONAL INFORMATION

NAME: First: __________________________ MI: ____ Last:______________________________

Do you have a valid Driver’s License?  Yes  No Do you have a provisional or permit?  Yes  No Driver’s License Number: __________________________ Driver’s License Expiration Date: ____________

Are you 21 years or older?  Yes  No

Is there any information regarding your current name or use of another name that NCIA would require in obtaining employment reference or criminal background information?  Yes  No

If Yes, please provide necessary information. __________________________________________

Present Address: ______________________________ Apt.________ City: ______________ State: ________

Zip Code: ___________ How long have you been at your present address? ______ Have you lived in another state in the past 10 years?  Yes  No If Yes, please list the cities, state(s), & years. :____________________

_______________________________________________________________________________________

Home Phone: __________________ Work Phone: __________________ Cell Phone: __________________

E-mail Address: _________________________________

ADDITIONAL INFORMATION How did you learn about NCIA?

 Referred by Employee (Name/Position/Relationship)__________________________________________

 School/College _____________________  Friend/Relative (Not Employee)

 Newspaper_________________________  Maryland Job Service

 Internet Job Board___________________  NCIA Website  Other _________________________

Have you ever been employed with NCIA?  Yes  No If Yes: Start Date: ______ End Date: _______

Position(s): _______________________________ Why did you leave? ________________________

Do you have relatives currently employed with NCIA?  Yes  No

If Yes: Name: __________________ Relationship: ____________ Position:_______________

Are you legally eligible for employment in the United States?  Yes  No

In order to comply with the Immigration Act of 1986, a new employee must supply documents that provide identity and employment

eligibility within three (3) business days of hire in order to complete the I-9 form. Because of the importance of this requirement, its

receipt is a condition of your employment.

Have you ever been convicted of ANY crime, other than traffic violations?  Yes  No

If yes, please provide information. NCIA performs criminal background checks on all employees. Failure to provide complete and accurate information constitutes falsification of documents and could preclude you from employment with NCIA.

Charge(s) Conviction Date Felony or Misdemeanor? Disposition

If you are applying for a direct care position, do you have any condition that would preclude you from performing physical restraint if necessary?  Yes  No

Due to the nature of the work environment at NCIA, physical restraint of individuals may be required. For safety reasons, the ability to perform this function is an essential function for all direct care staff.

If a job offer is made, how soon will you be available to work? ________________________

Do you have any objections to work overtime?  Yes  No Can you work overtime without prior notice?  Yes  No EDUCATION

Please list your educational background. Include GED, High School, College and/or Technical & Trade Schools.

If a job offer is extended, you will be required to provide educational documentation at time of employment.

Name, Address of School # of Yrs. Grad? Y/N Degree Major

ADDITIONAL RELATED TRAINING

Include all other training relevant to the position for which you have applied (i.e. CPR, First Aid, DDA & YIT Training, Med Administration, Computer Skills, and workshops attended. Please include date training was completed and expiration dates. Use additional sheets as required.

Training Date (Month/Year) Expiration Date Where Received

PROFESSIONAL REFERENCES

Name:_____________________________ Relationship to you:______________ Occupation:_____________

Address:____________________________________ City: __________________ State:____ Zip:__________

Phone: Day: ______________________ Evening:_______________________ Years Known:____________

Name:____________________________ Relationship to you:_______________ Occupation:_____________

Address:____________________________________ City: __________________ State:____ Zip:__________

Phone: Day: ______________________ Evening:_______________________ Years Known:____________

Name:____________________________ Relationship to you:_______________ Occupation:_____________

Address:____________________________________ City: __________________ State:____ Zip:__________

Phone: Day: ______________________ Evening:_______________________ Years Known:____________

EMPLOYMENT HISTORY

Please provide a complete and accurate job history for at least the last 6 years, beginning with the most recent.

Use additional sheets as required. NCIA performs employment reference checks on all employees. Failure to provide complete and accurate information could preclude you from employment with NCIA.

Current (or most recent) Employer:

Job Title: Supervisor: Employed: From (MM/YY) To (MM/YY) Phone:

FT or PT? Salary: If Current, may we contact?

 Yes  No Duties:

If Current, do you anticipate leaving if offered a position?  Yes  No Reason for Leaving:

Previous Employer:

Job Title: Supervisor: Employed: From (MM/YY)

To (MM/YY) Phone:

FT or PT? Salary:

Duties:

Reason for Leaving:

Previous Employer:

Job Title: Supervisor: Employed: From (MM/YY)

To (MM/YY) Phone:

FT or PT? Salary:

Duties:

Reason for Leaving:

Previous Employer:

Job Title: Supervisor: Employed: From (MM/YY)

To (MM/YY) Phone:

FT or PT? Salary:

Duties:

Reason for Leaving:

Other Employment and/or Volunteer Work: Provide a summary of any other employment or volunteer

activities (beyond the required 6 years) that would be relevant to the position for which you are applying.

NCIA IS AN EQUAL OPPORTUNITY EMPLOYER. WE WILL NOT DISCRIMINATE IN REGARDS TO AGE, SEX, RACE, NATIONAL ORIGIN, RELIGIOUS BELIEF OR PRACTICE, MARITAL

STATUS, POLITICAL AFFILIATION, SEXUAL ORIENTATION OR DISABILITY.

UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY

APPLICATION FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR

EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND

SUBJECT TO A FINE NOT TO EXCEED $100.

Applicant’s Signature:______________________________________________ Date:___________________

CHECK YOUR APPLICATION TO ENSURE THAT YOU HAVE ANSWERED EVERY QUESTION COMPLETELY AND ACCURATELY.

Only applications that are completed in their entirety will be considered for open positions with NCIA. This includes complete and correct addresses, phone numbers, and employment dates.

I certify that the information I have provided on this application and any resume is true and complete and that I have not knowingly withheld any information that would affect my application. I understand that any

misrepresentation, omission or concealment of facts is cause for dismissal. I authorize investigation of all statements contained in the application and resume.

In entering into employment with National Center on Institutions and Alternatives, Inc. (NCIA), I agree to observe all rules of my employer and to perform satisfactorily such duties as may be assigned to me. I understand that employment with NCIA is voluntarily entered into, and I am free to resign at will at any time, with or without cause.

Similarly, NCIA may terminate the employment relationship at will at any time, with or without cause, so long as there is no violation of applicable federal or state law. I understand that my employment is for no definite or fixed period of time. I understand that any continuation of employment shall depend upon performance that is

satisfactory at all times to my employer. Also, neither hours nor work, which may be assigned to me at any time, nor any other act or circumstance, shall constitute a guarantee of employment or continuation of assigned hours or work.

Applicant’s Signature:______________________________________________ Date:___________________

I understand that if I am employed by NCIA I will be required to have a criminal background check conducted and submit to a urinalysis, both at the expense of NCIA. I further understand that an initial physical examination and physician’s certificate will be required (in most positions), at my expense. I also understand and agree to provide an annual re-certification of my health, also at my expense.

Applicant’s Signature:______________________________________________ Date:___________________

I understand that most positions require the successful completion of specific trainings and re-certifications to the position as mandated by the regulatory agencies that license NCIA. I understand that failure to attend or

successfully complete this required training will preclude me from continued employment with NCIA.

Applicant’s Signature:______________________________________________ Date:___________________

STATEMENT REGARDING HOURS OF AVAILABILITY

Name:_____________________________________ Position Applying For:__________________________

NCIA understands that employees have interests and obligations other than their work. We encourage our employees to pursue family involvement, religious activities and continued education. We realize that it is necessary to work around other obligations such as childcare and other employment.

Therefore, in an effort to make the scheduling process most effective and satisfying for both the employee and supervisor we are requiring each applicant to submit their exact hours of availability, keeping other interests and obligations in mind. Submitting your availability does not guarantee a specific schedule, a specific amount of hours, or the change of any published schedule. Your submission of your hours of availability will not excuse you from meeting your training requirements.

IF APPLYING FOR DIRECT CARE PLEASE MARK ANY AND ALL HOURS/SHIFTS THAT YOU ARE AVAILABLE FOR WORK.

Please note: Typical hours for staffing our Residential houses are Monday – Friday between the hours of 3 pm and 8 or 9 am as well as 24 hours on weekends and holidays. Direct Care Residential Staff will be expected to work during these hours/shifts.

7am – 3pm 8am – 4pm 3pm – 11pm 4pm – 12 midnight 11pm – 7am 11pm – 9 am 12 midnight – 8am SUNDAY

MONDAY TUESDAY WEDNESDAY

THURSDAY FRIDAY SATURDAY

I acknowledge that the submission of my Hours of Availability does not constitute a guarantee of a specific schedule or a specific amount of hours. I also acknowledge that my Hours of Availability does not preclude me from meeting my training obligations.

Applicant’s Signature:_____________________________________________ Date:___________________

I am aware that this information will become a part of my personnel file and be used in the creation of my work schedules. If my hours of availability change, I must give notice to my Supervisor 30 days prior to the change. I understand that my scheduled hours may be reduced due to my new hours of availability.

Applicant’s Signature:_____________________________________________ Date:___________________

National Center on Institutions and Alternatives 7205 Rutherford Road

Baltimore, MD 21244 Phone: 443-780-1300

AUTHORIZATION TO VERIFY INFORMATION

It is the policy of the National Center on Institutions and Alternatives (NCIA) to verify current/previous employment, transcripts from educational institutions, conduct criminal background checks and obtain any other information required by the licenses under which NCIA operates. Please sign the bottom of this page to

authorize the release of the necessary information.

I authorize _______________________________________________ to provide the requested information to the National Center on Institutions and Alternatives (NCIA). I release your company and its employees from all liability from any damage that may result from providing such information.

I hereby consent to NCIA verifying all the information I have provided on this application form. I also agree to execute as a condition of employment or a condition of continued employment any additional written

authorizations necessary for the company to obtain access to and copies of records pertaining to this

information. I also hereby authorize NCIA’s access to any medical histories or records pertaining to me (and any other individuals who, due to my employment, may be covered by any company medical or other insurance program).

With regard to the foregoing disclosures, I hereby agree to release any person, company, or other entity from any and all causes of action that otherwise might arise from supplying NCIA with information it may request

pursuant this release. I understand that any false answers or statements, or misrepresentations by omission, made by me on the application may be cause for my immediate discharge, even when such falsifications or

misrepresentations are discovered after I am employed.

Applicant’s Name (Print):_________________________________________

Applicant’s Signature:_____________________________________________ Date:___________________

Thank you for your cooperation.