2. Full Legal Name _____________________________________________________________________________Last First Middle

3. Address ____________________________________________________________________________________Number and Street

City State Zip

4. Home Phone ( ) ___________________________ 5. Business Phone ( )________________________

_________________________________________________________________________________________________A FINGERPRINT-BASED CRIMINAL HISTORY RECORD CHECK, CHILD ABUSE AND NEGLECT REGISTRY CHECK,

DMV CHECK, DRUG TEST AND VERIFICATION OF CREDENTIALS ARE REQUIRED ON APPLICANTS CONSIDERED FOR EMPLOYMENT

___________________________________________________________________________________________________________________No person shall, on the grounds of race, color, national origin, sex, religion, age or handicapping condition, be excluded from participation in, be denied benefits of, or otherwise be subjected to discrimination in the provision of any care of service. __________________________________________________________________________________________________________________PLEASE READ THESE INSTRUCTIONS BEFORE YOU COMPLETE YOUR APPLICATION.

PIEDMONT COMMUNITY SERVICES EMPLOYMENT APPLICATION

An Equal Opportunity Employer

Applications are only accepted for jobs in which are currently open. Be sure to list the title of the job you are applying for in the same way it appears in the job announcement. Complete the entire application. Incomplete applications will not be considered. __________________________________________________________________________________________________

1. Position Applied For ________________________________ Position #

___________________________

_________________________________________________________________________

(One Per Application)