Application for Employment

Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application for employment is true and complete. I agree that any false information in support of my application may subject me to discharge at any time during the period of my employment. I authorize any insurance company, employer, educational institution, law enforcement organization, state and federal agency including Nebraska’s Department of Labor, Information Services Bureau, medical facility, and other persons contacted to release or to verify any of the information regarding my character, performance, qualifications, background, prior disciplinary employment record, and reasons for termination of past employment to requesting Employer or its agent and release all parties involved in providing said information from any responsibility or liability. I also authorize the release of my driving history, criminal records, worker compensation records, and understand that they may contain information about my background, mode of living, character, and personal reputation. I acknowledge that a telephone facsimile or photographic copy shall be as valid as the original. I understand and agree that a job offer from The Grace Space is contingent upon the background checks required by the company and a clean drug test done upon hire and randomly thereafter and nothing negative on my physical. If hired, I agree I will serve at the will of the company and further agree that I shall be bound by the rules, policies, regulations and terms and conditions of employment of the firm as they are from time-to-time changed with or without notice to me. I agree that either party may terminate the employment relationship, with or without cause, at any time for any reason. I hereby authorize the company to deduct from each and every period of my pay any amounts necessary to offset any damages caused by me or the value of property or money entrusted to me by, or owed by me to the firm during the course of my employment. I agree that these arrangements may only be altered in writing directed to me personally by the Administrator. I further agree that if I should bring any action or claim arising out of my employment against the company in which the company prevails, I will pay to the company any and all costs incurred by the company in defense of said claims or actions, including attorney’s fees.

Agency request for information from the Nebraska Adult and Child Abuse and Neglect Registry

I hereby request information from the Nebraska Adult and Child Abuse and Neglect Registry. I agree to use the requested information to determine whether to hire or retain the individual to provide care, custody, treatment, transportation or supervision of children or vulnerable adults. Agency Name: The Grace Space Address: 1740 Superior Lincoln, NE 68521 Phone: (402) 770-9089 I hereby authorize the Division of Children and Family Services to disclose whether I have an Adult and/or Child Abuse and Neglect Registry record to the above-named agency.

Criminal Background Investigation Report