Application for Employment Form

Floyd County Housing Authority_logo
Phone: 606.285.3833 | Fax: 606.285.3835
402 John M. Stumbo Drive, Langley, KY 41645
FCHA-KY.org

Equal Housing Opportunity logo, Handicapped Accessible logo, and Website Accessible logo

[{"type":"text","required":true,"label":"Name (Last, First)","name":"Name-Last-First-Middle-Initial","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Social Security Number","name":"Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Present Address","name":"present-address","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Present Apartment Number","name":"present-apartment-number","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Present City","name":"Present-City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"Present State","name":"State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of 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Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Present Zip Code","name":"Present-Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Permanent Address","name":"Permanent-Address","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Permanent Apartment Number","name":"permanent-apartment-number","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Permanent City","name":"permanent-city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"Permanent State","name":"Permanent-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY","selected":true},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Permanent Zip Code","name":"permanent-zip-code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"radio-group","required":true,"label":"Are You 18 Years or Older?","inline":true,"name":"Are-You-18-Years-or-Older","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","required":true,"label":"Do You Have the Legal Right to Work in the United States?","inline":true,"name":"Do-You-Have-the-Legal-Right-to-Work-in-the-United-States","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","required":true,"label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">Home Phone Number</span>","name":"Home-Phone-Number","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Cell Phone Number","name":"Cell-Phone-Number","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"Email","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"Email-Confirmation","className":"col-md-6 col-lg-3"},{"type":"radio-group","label":"Do You Have a Valid Driver's License?","inline":true,"name":"Do-You-Have-a-Valid-Drivers-License","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"If yes, give Driver's License Number and Class of License","name":"If-yes-give-Drivers-License-Number-and-Class-of-License","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<b>Desired Employment</b>","className":"d-block"},{"type":"text","label":"Position","name":"Position","className":"d-block","subtype":"text"},{"type":"date","label":"Date You Can Start","name":"Date-You-Can-Start","className":"col-md-6"},{"type":"text","label":"Salary Desired","name":"Salary-Desired","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Are You Employed Now?","inline":true,"name":"Are-You-Employed-Now","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;=\"\" font-weight:=\"\" 700;\"=\"\">If So, May We Inquire of Your Present Employer?</span>","inline":true,"name":"If-So-May-We-Inquire-of-Your-Present-Employer","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Have You Ever Applied to this Company Before?","inline":true,"name":"Have-You-Ever-Applied-to-this-Company-Before","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Have You Ever Worked for this Company Before?","inline":true,"name":"Have-You-Ever-Worked-for-this-Company-Before","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Where You Previously Applied","name":"Where-You-Previously-Applied","className":"col-md-6","subtype":"text"},{"type":"text","label":"When you Previously Applied","name":"When-you-Previously-Applied","className":"col-md-6","subtype":"text"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">Where You Previously Worked for This Company</span>","name":"Where-You-Previously-Worked-for-This-Company","className":"col-md-6","subtype":"text"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">When You Previously Worked for This Company</span>","name":"When-You-Previously-Worked-for-This-Company","className":"col-md-6","subtype":"text"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">Reason for Leaving</span>","name":"Reason-for-Leaving","className":"d-block","subtype":"text"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">Name Of Last Supervisor At This Company</span>","name":"Name-Of-Last-Supervisor-At-This-Company","className":"d-block","subtype":"text"},{"type":"checkbox-group","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;=\"\" font-weight:=\"\" 700;\"=\"\">Who Referred You To This Company?</span><br>","inline":true,"name":"Who-Referred-You-To-This-Company","other":true,"className":"d-block","values":[{"label":" Employment Agency","value":" employment agency"},{"label":" Newspaper Advertising","value":" newspaper advertising"},{"label":" Friend","value":" friend"},{"label":" State Employment Office","value":" state employment office"},{"label":" College Placement Service","value":" college placement service"},{"label":" Walk In","value":" walk in"}]},{"type":"radio-group","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;=\"\" font-weight:=\"\" 700;\"=\"\">Do You Have Any Relatives Working for the Authority?</span>","inline":true,"name":"Do-You-Have-Any-Relatives-Working-for-the-Authority","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Do You Have Any Relatives on The BOC?<br>","inline":true,"name":"Do-You-Have-Any-Relatives-on-The-BOC","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No ","value":" no"}]},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">If Yes, Who, What Is Their Position, And What Is Their Relationship To You?</span>","name":"If-Yes-Who-What-Is-Their-Position-And-What-Is-Their-Relationship-To-You","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h3","label":"Education","className":"d-block"},{"type":"header","subtype":"h4","label":"High School","className":"d-block"},{"type":"text","label":"High School Name","name":"high-school-name","className":"col-md-6","subtype":"text"},{"type":"text","label":"High School Address","name":"high-school-address","className":"col-md-6","subtype":"text"},{"type":"header","subtype":"h4","label":"College 1","className":"d-block"},{"type":"text","label":"College 1 Name","name":"College-1-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"College 1 Address","name":"College-1-Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"College 1 Type of Degree","name":"College-1-Type-of-Degree","className":"col-md-6","subtype":"text"},{"type":"date","label":"College 1 Graduation Date","name":"College-1-Graduation-Date","className":"col-md-6"},{"type":"header","subtype":"h4","label":"College 2","className":"d-block"},{"type":"text","label":"College 2 Name","name":"College-2-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"College 2 Address","name":"college-2-address","className":"col-md-6","subtype":"text"},{"type":"text","label":"College 2 Type of Degree","name":"College-2-Type-of-Degree","className":"col-md-6","subtype":"text"},{"type":"date","label":"College 2 Graduation Date","name":"College-2-Graduation-Date","className":"col-md-6"},{"type":"header","subtype":"h3","label":"Special Courses and Certifications","className":"d-block"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">Special Courses (Please Include School Name, Types of Courses, Credits)</span>","name":"Special-Courses-Please-Include-School-Name-Types-of-Courses-Credits","className":"d-block","subtype":"text"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\">Certifications</span>","name":"Certifications","className":"d-block","subtype":"text"},{"type":"radio-group","label":"<legend style=\"border-width: 0px; border-style: initial; padding-right: 0.1875rem; padding-left: 0.1875rem; margin: 0px 0px 0px -0.1875rem; color: rgb(34, 34, 34); font-family: \" noto=\"\" serif\",=\"\" serif,=\"\" frutiger,=\"\" \"frutiger=\"\" linotype\",=\"\" univers,=\"\" calibri,=\"\" \"gill=\"\" sans\",=\"\" sans=\"\" mt\",=\"\" \"myriad=\"\" pro\",=\"\" myriad,=\"\" \"dejavu=\"\" condensed\",=\"\" \"liberation=\"\" \"nimbus=\"\" l\",=\"\" tahoma,=\"\" geneva,=\"\" \"helvetica=\"\" neue\",=\"\" helvetica,=\"\" arial,=\"\" sans-serif;=\"\" font-size:=\"\" 16px;\"=\"\"><legend style=\"border-width: 0px; border-style: initial; padding-right: 0.1875rem; padding-left: 0.1875rem; margin: 0px 0px 0px -0.1875rem; font-size: 16px;\">Have you attended/completed any training courses in working with children?</legend><div><br></div></legend>","inline":true,"name":"Have-you-attendedcompleted-any-training-courses-in-working-with-children","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"<div><font color=\"#222222\" face=\"Noto Serif, serif, Frutiger, Frutiger Linotype, Univers, Calibri, Gill Sans, Gill Sans MT, Myriad Pro, Myriad, DejaVu Sans Condensed, Liberation Sans, Nimbus Sans L, Tahoma, Geneva, Helvetica Neue, Helvetica, Arial, sans-serif\"><span style=\"font-size: 16px;\">Have you had CPR training within the past two years?</span></font></div>","inline":true,"name":"Have-you-had-CPR-training-within-the-past-two-years","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Have you had First Aid training within the past three years?","inline":true,"name":"Have-you-had-First-Aid-training-within-the-past-three-years","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":"no"}]},{"type":"date","label":"<div>Expiration Date of CPR Training</div>","name":"Expiration-Date-of-CPR-Training","className":"col-md-6"},{"type":"date","label":"Expiration Date of First Aid Training","name":"Expiration-Date-of-First-Aid-Training","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Former Employers","className":"d-block"},{"type":"header","subtype":"h4","label":"Employer 1","className":"d-block"},{"type":"text","label":"Name of Present or Last Employer","name":"Name-of-Present-or-Last-Employer","className":"d-block","subtype":"text"},{"type":"text","label":"Employer 1 - Address","name":"Employer-1---Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer 1 - City","name":"Employer-1---City","className":"col-md-6","subtype":"text"},{"type":"select","label":"Employer 1 - State","name":"Employer-1---State","className":"col-md-6","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY","selected":true},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","label":"Employer 1 - Zip","name":"Employer-1---Zip","className":"col-md-6","subtype":"text"},{"type":"date","label":"Employer 1 - Starting Date","name":"Employer-1---Starting-Date","className":"col-md-6 col-lg-3"},{"type":"date","label":"Employer 1 - Leaving Date","name":"Employer-1---Leaving-Date","className":"col-md-6 col-lg-3"},{"type":"text","label":"Employer 1 - Job Title","name":"Employer-1---Job-Title","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer 1 - Weekly Starting Salary","name":"Employer-1---Weekly-Starting-Salary","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer 1 - Weekly Final Salary","name":"Employer-1---Weekly-Final-Salary","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Employer 1 - May we contact your supervisor?","inline":true,"name":"Employer-1---May-we-contact-your-supervisor","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Employer 1 - Name of Supervisor","name":"Employer-1---Name-of-Supervisor","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 1 - Supervisor Title","name":"Employer-1---Supervisor-Title","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 1 - Supervisor Phone","name":"Employer-1---Supervisor-Phone","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 1 - Description of Work","name":"Employer-1---Description-of-Work","className":"d-block","subtype":"text"},{"type":"text","label":"Employer 1 - Reason for Leaving","name":"Employer-1---Reason-for-Leaving","className":"d-block","subtype":"text"},{"type":"header","subtype":"h4","label":"Employer 2","className":"d-block"},{"type":"text","label":"Name of Previous Employer - 2","name":"Name-of-Previous-Employer---2","className":"d-block","subtype":"text"},{"type":"text","label":"Address of Previous Employer - 2","name":"Address-of-Previous-Employer---2","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer 2 - City","name":"Employer-2---City","className":"col-md-6","subtype":"text"},{"type":"select","label":"<div><br></div><div>Employer 2 - State</div>","name":"-Employer-2---State","className":"col-md-6","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY","selected":true},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North 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Title","name":"Employer-2---Job-Title","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer 2 - Weekly Starting Salary","name":"Employer-2---Weekly-Starting-Salary","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Employer 2 - Weekly Final Salary</div>","name":"Employer-2---Weekly-Final-Salary","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Employer 2 - May we contact your supervisor?","inline":true,"name":"Employer-2---May-we-contact-your-supervisor","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Employer 2 - Name of Supervisor","name":"Employer-2---Name-of-Supervisor","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 2 - Supervisor Title","name":"Employer-2---Supervisor-Title","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 2 - Supervisor Phone","name":"Employer-2---Supervisor-Phone","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 2 - Description of Work","name":"Employer-2---Description-of-Work","className":"d-block","subtype":"text"},{"type":"text","label":"Employer 2 - Reason for Leaving","name":"Employer-2---Reason-for-Leaving","className":"d-block","subtype":"text"},{"type":"header","subtype":"h4","label":"Employer 3","className":"d-block"},{"type":"text","label":"Name of Previous Employer - 3","name":"Name-of-Previous-Employer---3","className":"d-block","subtype":"text"},{"type":"text","label":"Employer 3 - Address","name":"Employer-3---Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer 3 - City","name":"Employer-3---City","className":"col-md-6","subtype":"text"},{"type":"select","label":"Employer 3 State","name":"Employer-3-State","className":"col-md-6","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY","selected":true},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","label":"Employer 3 - Zip","name":"Employer-3---Zip","className":"col-md-6","subtype":"text"},{"type":"date","label":"Employer 3 - Starting Date","name":"Employer-3---Starting-Date","className":"col-md-6 col-lg-3"},{"type":"date","label":"Employer 3 - Leaving Date","name":"Employer-3---Leaving-Date","className":"col-md-6 col-lg-3"},{"type":"text","label":"Employer 3 - Job Title","name":"Employer-3---Job-Title","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer 3 - Weekly Starting Salary","name":"Employer-3---Weekly-Starting-Salary","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Employer 3 - Weekly Final Salary</div>","name":"Employer-3---Weekly-Final-Salary","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Employer 3 - May we contact your supervisor?","inline":true,"name":"Employer-3---May-we-contact-your-supervisor","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Employer 3 - Name of Supervisor","name":"Employer-3---Name-of-Supervisor","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 3 - Supervisor Title","name":"Employer-3---Supervisor-Title","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 3 - Supervisor Phone","name":"Employer-3---Supervisor-Phone","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer 3 - Description of Work","name":"Employer-3---Description-of-Work","className":"d-block","subtype":"text"},{"type":"text","label":"Employer 3 - Reason for Leaving","name":"Employer-3---Reason-for-Leaving","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"References","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<p class=\"small-12 medium-12 large-12 columns\" id=\"control-5473310\" style=\"position: relative; width: 1127px; float: left; color: rgb(34, 34, 34); font-family: "Noto Serif", serif, Frutiger, "Frutiger Linotype", Univers, Calibri, "Gill Sans", "Gill Sans MT", "Myriad Pro", Myriad, "DejaVu Sans Condensed", "Liberation Sans", "Nimbus Sans L", Tahoma, Geneva, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px;\">Below, give the names of three persons you are not related to, whom you have known at least one year.</p><div><br></div><div class=\"small-12 medium-6 large-3 columns column-padding\" style=\"position: relative; width: 281.75px; float: left; padding-right: 0.9375rem; padding-left: 0.9375rem; color: rgb(34, 34, 34); font-family: "Noto Serif", serif, Frutiger, "Frutiger Linotype", Univers, Calibri, "Gill Sans", "Gill Sans MT", "Myriad Pro", Myriad, "DejaVu Sans Condensed", "Liberation Sans", "Nimbus Sans L", Tahoma, Geneva, "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 16px;\"></div>","className":"d-block"},{"type":"text","label":"Reference 1 - Name","name":"Reference-1---Name","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 1 - Address","name":"Reference-1---Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"<div><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">Reference 1 - Business</span><br></div>","name":"Reference-1---Business","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 1 - Years Acquainted","name":"Reference-1---Years-Acquainted","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"<div><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">Reference 2 - Name</span><br></div>","name":"Reference-2---Name","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"<div>Reference 2 - Address</div>","name":"Reference-2---Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 2 - Business","name":"Reference-2---Business","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 2 - Years Acquainted","name":"Reference-2---Years-Acquainted","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 3 - Name","name":"Reference-3---Name","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 3 - Address","name":"Reference-3---Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 3 - Business","name":"Reference-3---Business","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Reference 3 - Years Acquainted","name":"Reference-3---Years-Acquainted","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Service Record","className":"d-block"},{"type":"text","label":"Branch of Service","name":"Branch-of-Service","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Discharge Rank","name":"Discharge-Rank","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Discharge Date","name":"Discharge-Date","className":"col-lg-4"},{"type":"text","label":"Additional Service Information","name":"Additional-Service-Information","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","label":"Have you ever been discharged or forced to resign from a position?","inline":true,"name":"Have-you-ever-been-discharged-or-forced-to-resign-from-a-position","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Have you been convicted of a felony within the last 5 years?","inline":true,"name":"Have-you-been-convicted-of-a-felony-within-the-last-5-years","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"If yes to either, explain (will not necessarily exclude you from consideration)","name":"If-yes-to-either-explain-will-not-necessarily-exclude-you-from-consideration","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Do you have a criminal record?","inline":true,"name":"Do-you-have-a-criminal-record","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","label":"If you do have a criminal record, explain","name":"If-you-do-have-a-criminal-record-explain","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Have you received any traffic violations in the past 2 years?","inline":true,"name":"Have-you-received-any-traffic-violations-in-the-past-2-years","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"If yes to traffic violations, explain","name":"If-yes-to-traffic-violations-explain","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Have you ever been shown by credible evidence, e.g., a court order or jury, a department's investigation or other reliable evidence to have abused, neglected or deprived a child or adult or to have subjected any person to serious injury of intentional or grossly negligent misconduct?","inline":true,"name":"Have-you-ever-been-shown-by-credible-evidence-eg-a-court-order-or-jury-a-departments-investigation-or-other-reliable-evidence-to-have-abused-neglected-or-deprived-a-child-or-adult-or-to-have-subjected-any-person-to-serious-injury-of-intentional-or-grossly-negligent-misconduct","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" yes"}]},{"type":"paragraph","subtype":"p","label":"Under the American with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability. The reasonable accommodation requirement applies to the application process, any pre-employment testing, interviews and actual employment, but only if the program supervisor is made aware that an accommodation is required. If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.","className":"d-block"},{"type":"radio-group","required":true,"label":"<div><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">Having read the job description for the position for which you are applying, are you in all respects, able to adequately perform the duties as described?</span><br></div>","inline":true,"name":"Having-read-the-job-description-for-the-position-for-which-you-are-applying-are-you-in-all-respects-able-to-adequately-perform-the-duties-as-described","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"If no, please explain.","name":"If-no-please-explain","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Interview Questionnaire","className":"d-block"},{"type":"text","label":"1. Why do you want to work with our company for the position in which you applied?","name":"1-Why-do-you-want-to-work-with-our-company-for-the-position-in-which-you-applied","className":"d-block","subtype":"text"},{"type":"text","label":"2. What can you offer our company/department?","name":"2-What-can-you-offer-our-companydepartment","className":"d-block","subtype":"text"},{"type":"text","label":"3. What are your goals for working with our company?","name":"3-What-are-your-goals-for-working-with-our-company","className":"d-block","subtype":"text"},{"type":"text","label":"4. Describe a time when you had a disagreement with a supervisor or a co-worker. How did you handle it?","name":"4-Describe-a-time-when-you-had-a-disagreement-with-a-supervisor-or-a-co-worker-How-did-you-handle-it","className":"d-block","subtype":"text"},{"type":"text","label":"<div>5. How well do you work with others?</div>","name":"5-How-well-do-you-work-with-others","className":"d-block","subtype":"text"},{"type":"text","label":"6. Most of our positions require some evenings, weekend and traveling out of town. Are you flexible? Yes/No, please explain.","name":"6-Most-of-our-positions-require-some-evenings-weekend-and-traveling-out-of-town-Are-you-flexible-YesNo-please-explain","className":"d-block","subtype":"text"},{"type":"text","label":"7. Is there any additional information that you would like to offer?","name":"7-Is-there-any-additional-information-that-you-would-like-to-offer","className":"d-block","subtype":"text"},{"type":"text","label":"8. Do you have any planned vacations within the next 3 months that will prevent you from being able to work?","name":"8-Do-you-have-any-planned-vacations-within-the-next-3-months-that-will-prevent-you-from-being-able-to-work","className":"d-block","subtype":"text"},{"type":"text","label":"9. Why should I/we hire you for the position you have applied for?","name":"9-Why-should-Iwe-hire-you-for-the-position-you-have-applied-for","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"(For Statistical Purposes Only)","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Pursuant to federal regulations, we collect responses to the questions below for record keeping purposes. This information will not be kept with your application for employment. Federal law prohibits unlawful discrimination on the basis of race, color, sex, national origin, religion or disability.","className":"d-block"},{"type":"select","label":"Highest level of education you have completed","name":"Highest-level-of-education-you-have-completed","className":"col-md-6","values":[{"label":" (Select One)","value":" (Select One)","selected":true},{"label":" Less Than 8th Grade","value":" less than 8th grade"},{"label":" Completed 8th Grade","value":"  completed 8th grade"},{"label":" Attended High School","value":" attended high school"},{"label":" High School Graduate or Equivalent","value":" high school graduate or equivalent"},{"label":" Attended College","value":" attended college"},{"label":" Associate's Degree","value":" associate's degree"},{"label":" Bachelor's Degree","value":" bachelor's degree"},{"label":" Master's Degree","value":" master's degree"},{"label":" Attended Graduate School","value":" attended graduate school"},{"label":" PHD or Professional Degree","value":" phd or professional degree"},{"label":" Graduate Studies Beyond Master's Requirements","value":" graduate studies beyond master's requirements"}]},{"type":"select","label":"Sex","name":"Sex","className":"col-md-6","values":[{"label":" (Select One)","value":" (Select One)","selected":true},{"label":" Male","value":" male"},{"label":" Female","value":" female"}]},{"type":"select","label":"Racial or ethnic group with which you identify","name":"Racial-or-ethnic-group-with-which-you-identify","className":"d-block","values":[{"label":" (Select One)","value":" (Select One)","selected":true},{"label":" White (includes Arabian)","value":" white (includes arabian)"},{"label":"Black (Includes Jamaican, Bahamians, and other Caribbean of African but not Hispanic or Arabian Descent)","value":"black (includes jamaican, bahamians, and other caribbean of african but not hispanic or arabian descent)"},{"label":"Hispanic (Includes persons of Mexican, Puerto  Rican, Central or South American or other Spanish origin or culture)","value":"Hispanic (Includes persons of Mexican, Puerto  Rican, Central or South American or other Spanish origin or culture)"},{"label":"Asian and Asian American (Includes Pakistanis, Indians, and Pacific Islanders)","value":"Asian and Asian American (Includes Pakistanis, Indians, and Pacific Islanders)"},{"label":"American Indians (Includes Alaskans)","value":"American Indians (Includes Alaskans)"}]},{"type":"date","label":"Date of Birth","name":"Date-of-Birth","className":"col-md-6"},{"type":"text","label":"Position Applied For","name":"Position-Applied-For","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Authorization to Release Personal Information","className":"d-block"},{"type":"paragraph","subtype":"p","label":"\"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. <br><br><div>I authorize investigations of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information. <br><br>I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.\"<br><br></div><div>\"I certify that all the information submitted by me on this application is true and complete and I understand that if any false information omission or misrepresentations are discovered, my application may be rejected and, if I am employed my employment may be terminated at any time. In consideration of my employment I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated with or without notice at any time by the company. I understand that no company representative other than its president and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.\"</div>","className":"d-block"},{"type":"text","required":true,"label":"Authorization Signature","placeholder":"By typing your name you are signing this form","name":"Authorization-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Authorization Signature Date","name":"Authorization-Signature-Date","className":"col-md-6"},{"type":"header","subtype":"h3","label":"Floyd County Housing Authority (FCHA) Statement of Confidentiality","className":"d-block"},{"type":"paragraph","subtype":"p","label":"The success of the Housing Authority of Floyd County depends to a substantial extent upon the degree of confidentiality. For some, coming to an agency such as the Housing Authority of Floyd County can be a very frightening experience, especially when clients may be concerned that friends or neighbors may find out they are seeking assistance. It is essential that everyone affiliated with the Housing Authority of Floyd County (employees, board members, students, and volunteers) have a commitment to confidentiality. This involves respecting the clients' rights to privacy and creating a level of trust so client may receive effective services through open discussions and dialogue. The policy of confidentiality, as set forth below, will be adhered to:<br><br>1. DO NOT disclose to anyone, the name or identity of clients unless it is necessary for the purpose of providing services. Take particular caution of disclosure to family, friends, or other agencies.<br><br>2. DO NOT discuss a client's situation with non-staff persons. This includes telephone calls or messages from clients; be especially careful about discussing a client to their situation openly in front of others.<br><br>3. DO NOT leave telephone messages or notes regarding client phone calls lying around in an open area. All messages should be processed and held in strict confidence.<br><br>4. DO NOT release client information to outside inquirers without appropriate verification of callers.<br><br>5. DO be aware of your surroundings when discussing a client or using a client's name. Keep all client records and/or documentation secured to the extent possible.<br><br>6. Do handle inquiries from outside regarding clients or co-workers in the appropriate manner. Refer inquires to the CEO or supervisory level staff. This includes verification of employment of past and current co-workers/employees, as well as verification of services to clients.<br><br>I understand and hereby agree to hold all information obtained in the course of employment with the Housing Authority of Floyd County in the strictest confidence. My signature implies that I respect the privacy of clients, the Agency, and its employees, and will not inappropriately discuss or disclose any information regarding client cases to which I have been assigned, and/or have access to.<br><br>I will also abide by the confidentiality requirements set forth herein. I agree to deliver promptly to the CEO at termination of my employment, or any other time at the CEO request, without retaining any copies, all documents and other materials in my possession relating, directly, and indirectly, to any confidential information","className":"d-block"},{"type":"text","required":true,"label":"Confidentiality Statement Signature","placeholder":"By typing your name you are signing this form.","name":"Confidentiality-Statement-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Confidentiality Statement Signature Date","name":"Confidentiality-Statement-Signature-Date","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"}]