Were you ever indicted or convicted of child abuse? Were you ever convicted of a criminal
offense? (Omit minor traffic violations and any offense committed before your 18th birthday that
was finally adjudicated in a juvenile court or under a youth offender law.) If yes, give details on
a separate sheet of paper. Conviction of a criminal offense is not a bar to employment in all
cases. Each case is considered on its merits.
Please include any additional information that you think would be applicable: e.g., volunteer experience, internships, membership in professional organizations. Exclude any information which would describe race, sex, age, marital status, national origin, religious or political affirmations.
I hereby certify that the information provided by me in this application is true to the best of my
knowledge. I understand that any misrepresentation or falsification made to Family Services
can be grounds for refusal of employment. I further understand that, if employed, any false
statement or misrepresentation provided by me herein or in conjunction with the application
process may be cause for dismissal.
I understand and agree that the employment relationship that may result from my application will be at will, and either Family Services or I may terminate the employment relationship at any time.
I authorize Family Services to verify any statements made in this application or provided during
the application process. I also authorize Family Services to contact the references and previous
employer(s) listed on my application, unless explicitly indicated otherwise.