Speech Language Pathology Application

Speech Language Pathology Application
Date *

Month Day Year
Date Hour Minutes AM/PM Option
Name *

First Name Middle Name Last Name
Preferred Name
Phone Number *

Area Code Phone Number
Email *
Social Security Number *
123-45-6789
Date of Birth *

Month Day Year
Drivers License *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date available to start *

Month Day Year
Date
Employment Type *
Are you authorized to work in the United States? *
Have you ever been convicted of a crime? *
If yes, please explain:
Have you ever been employed with Easterseals? *
If yes, please indicate when, where, and what position that you held with Easterseals.
Education:

This position requires a Master’s or higher degree in Speech-Language Pathology or Communicative Sciences and Disorders from an accredited College of University.
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*
Licensure:

This position requires a Valid South Carolina Speech-Language Pathology license.
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Employment History:
Most Recent position *
We require one year of experience in the field of early childhood education, OR one year experience working with infant and toddlers, OR one year experience with children age birth to 5 years with disabilities. Please tell us any experiences you have in this area: *
References:
*
Upload your Resume *

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If selected for an interview more forms will need to be completed.
Certification of Applicant:

By my signature, I affirm, agree, and understand that all information on this form is true and accurate. Any misrepresentation, falsification, or material omission of information or data on the application may result in exclusion from further consideration or if hired, termination of employment. If I have requested herein that my present employer not be contacted, an offer of employment may be conditioned upon acceptable information and verification from such employer prior to beginning work.
Signature *

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Therapy Division Applicant Consent Release
Caution to the applicant! Please read carefully
1. I understand that prior to an offer of employment with Easterseals South Carolina, that Easterseals South Carolina will order a South Carolina Department of Social Services(SCDSS) Central Registry of Child Abuse and Neglect Database Check, Federal Criminal Record Check (via the DHEC Direct Caregiver Application for Electronic Scan Bureau of Health Facilities Regulation electronic, fingerprint scan), and a South Carolina Law Enforcement Division (SLED) Criminal Records Check on me. If either report reveals any negative history, employment will not be offered. Please do not continue this Employment Application process if any of the checks listed in this section will reveal a negative history. My signature under #1 indicates that I understand this statement.
Applicant signature: *

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2. I understand that prior to an offer of employment with Easterseals South Carolina, that Easterseals South Carolina will complete the Centers for Medicare and Medicaid Services (CMS) List of Excluded Individuals/Entities (LEIE) Check on me. If the CMS LEIE reveals any negative history, employment will not be offered. Please do not continue this Employment Application process if your CMS LEIE report will reveal a negative history. My signature under #2 indicates that I understand this statement.
Applicant signature: *

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3. I understand that prior to an offer of employment with Easterseals South Carolina, that Easterseals South Carolina will order a South Carolina Department of Motor Vehicle (SCDMV) Request for Driver Information Report, as required by Easterseals South Carolina’s liability insurance carrier. If my SCDMV Request for Driver Information Report indicates more than two (2) moving violations or at-fault accidents within the three (3) years immediately preceding, then employment will not be offered. My Signature under #3 indicates that I understand this statement.
Applicant signature: *

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4. I understand that Easterseals South Carolina requires me to provide an official, sealed college transcript from all colleges or universities indicated on my application and/or resume, prior to the scheduled interview with Easterseals South Carolina. (Note: Photocopies of transcripts are not accepted. Transcripts must be official and sealed as provided and authenticated by the school providing the transcript). No offers of employment will be extended without official transcripts received by Easterseals South Carolina. My signature under #4 indicates that I understand this statement.
Applicant signature: *

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5. I understand that I must provide a sealed Letter of Reference from a former employer or a completed, sealed Service Letter from a former employer prior to the scheduled interview with Easterseals South Carolina. An offer of employment will not be extended without receipt of one of the letters stated above. My signature under #5 indicates that I understand this statement.
Applicant signature: *

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6. I understand that I must provide a copy of my automobile insurance card and the automobile insurance declaration page from my automobile insurance policy prior to the scheduled interview with Easterseals South Carolina. An offer of employment will not be extended without receipt of copies of documents stated above. My signature under #6 indicates that I understand this statement.
Applicant signature: *

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Upload Proof of Auto Insurance *

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I understand that if I am employed by Easterseals South Carolina, that all Federal and State Background Checks listed in #1, #2, and #3 will be checked throughout employment with Easterseals South Carolina. If at any time, my Federal or State Background Checks reveal a negative history, employment with Easterseals South Carolina may be terminated.

I understand that the items mentioned above are absolute requirements, and Easterseals South Carolina’s use of and reliance on these items are not negotiable. If you anticipate that one or more of these items will present a problem, then please address your concerns with the Easterseals South Carolina’s Director of Human Resources prior to submitting your completed application.

By my signature, I consent to the release of information to authorized officers, agents, and employees of the State of South Carolina, which may include, but not be limited to information concerning my past and present work; including my official personnel files; attendance records, evaluations, military service, law enforcement records; and any personnel record deemed necessary. In addition, I consent to authorize appropriate officers, agents, and employees of the State to make inquiries of third parties. I further release the organization, educational entity, present and former employers, law enforcement organizations, and all third parties from any and all claim of whatever nature that I may have as a result of any inquiry or response given to such inquiries made in connection with my application for employment.
Applicant signature: *

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Speech Language Pathology Application

Education:

Licensure:

Employment History:

References:

Therapy Division Applicant Consent Release