Apply Online Step 1 of 14 7% Good Samaritan Boys RanchAPPLICATION FOR EMPLOYMENT AN EQUAL OPPORTUNITY EMPLOYER Good Samaritan Boys Ranch does not discriminate on the basis of sex, race, color, religion, national origin, age, veteran status or handicap. This is a uniform application for employment and is used to fill all positions at the Ranch. The information requested will only be used to the extent it is relevant to the position. Privacy & Security Disclaimer The Boys Ranch website - ranchlife.org has an SSL certificate and a secure connection. The information that you share in this application will be kept private, and will only be viewed by those involved in the hiring and review process.DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Applicant certifies being 21 or older (initials): Name First Middle Initial Last PhonePresent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is this your permanent address? Yes No Permanent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Position SoughtYouthcareDarr House Program CoordinatorOvernight YouthcareSubstitute YouthcareSummer YouthcareTLS SupervisorInternMedical CoordinatorTherapistStabilization SpecialistPreferred Work LocationBrighton (Specialized Treatment Facility)Springfield (Footsteps Transitional Living)Willard (Laura’s Home)Check what you are interested in: Full Time Part Time Temporary Work weekends? Yes No Social Security Number: (Information can be submitted at a later time, if preferred) Current Salary: Salary Desired Emergency Contact: PhoneEmergency Contact: PhoneEmergency Contact: PhoneFamily Physician: PhonePERSONS AT THE RANCH WITH WHOM YOU ARE ACQUAINTED: Have you ever been convicted of a felony? Yes No If Yes, Please explain: Have you previously applied here? Yes No If yes, when? Have you previously been employed here? Yes No If yes, when? Are you currently or ever been employed by the State of Missouri? Yes No If yes, when? Do you have a reliable means of transportation to and from work? Yes No Signature of Applicant Pursuant to the Immigration Reform Act of 1986, all applicants, upon being made an offer of employment, must produce documents, which will be specified by the federal government, establishing their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two (72) hours after commencement of employment. You will also be required to sign Form I-9 issued by the federal government verifying under oath, your employment authorization EducationHigh School Diploma Yes No Year received GED Yes No Year received Education Cont.OTHER TRAINING (Trade, Technical, Correspondence, Military) Address COURSE HOURS, CREDITS OR CERTIFICATE OTHER TRAINING (Trade, Technical, Correspondence, Military) Address COURSE HOURS, CREDITS OR CERTIFICATE Education Cont.COLLEGE/GRADUATE SCHOOL (Grade Transcripts are Desirable)Name of School/College(s)MAJOR SUBJECTSCREDIT HOURS COMPLETEDDEGREE EARNED COLLEGE/GRADUATE SCHOOL (Grade Transcripts are Desirable)Name of School/College(s)MAJOR SUBJECTSCREDIT HOURS COMPLETEDDEGREE EARNED COLLEGE/GRADUATE SCHOOL (Grade Transcripts are Desirable)Name of School/College(s)MAJOR SUBJECTSCREDIT HOURS COMPLETEDDEGREE EARNED PROFESSIONAL OR TECHNICAL LICENSES HELD:License Number: State: Exp. Date: License Number: State: Exp. Date: License Number: State: Exp. Date: PROFESSIONAL REFERENCES (exclude relatives and completely fill out below in order to be considered):Reference #1Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneOccupation Years known Reference #2Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneOccupation Years known Reference #3Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneOccupation Years known PERSONAL REFERENCES (exclude relatives and completely fill out below in order to be considered):Reference #1Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneOccupation Years known Reference #2Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneOccupation Years known Reference #3Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneOccupation Years known PLEASE PROVIDE EMPLOYMENT INFORMATION FOR THE PAST FIVE YEARSHave you lived outside Missouri in the past five years? If “Yes” where: List All States and Addresses for previous 5 years Yes No State Dates Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country State Dates Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Present or Most recent position: May we contact your present employer? Yes No Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneReason for leaving Describe your position/duties:From: Month Day Year To: Month Day Year Job Title Dept: Supervisor: Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneReason for leaving Describe your position/duties:From: Month Day Year To: Month Day Year Job Title Dept: Supervisor: Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneReason for leaving Describe your position/duties:From: Month Day Year To: Month Day Year Job Title Dept: Supervisor: Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneReason for leaving Describe your position/duties:From: Month Day Year To: Month Day Year Job Title Dept: Supervisor: Please carefully read and sign below: I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I REALIZE THAT MISREPRESENTATION OF FACTS MAY BE CAUSE FOR REJECTION OF THE APPLICATION OR DISMISSAL AFTER EMPLOYMENT. FINAL EMPLOYMENT IS CONTINGENT UPON SATISFACTORY COMPLETION OF ALL PRE-EMPLOYMENT PROCEDURES INCLUDING INTERVIEW, VERIFICATION OF ALL RELEVANT INFORMATION AND THE APPROPRIATE PROBATIONARY PERIOD.Signature DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 APPLICANT DISCLOSURE AFFIDAVITOur agency screens prospective employees and volunteers to evaluate whether an applicant poses a risk of harm to the children and youth it serves. Information obtained is not an automatic bar to employment or volunteer work, but is considered in view of all relevant circumstances. This disclosure is required to be completed by applicants for positions in order to be considered. Any falsification, misrepresentation or incompleteness in this disclosure alone is grounds for disqualification or termination.Name First Last Social Security Number Please check each statement. (If you have not checked each statement, provide an explanation below) The undersigned applicant affirms that I HAVE NOT AT ANY TIME (whether as an adult or juvenile): Been convicted of; Pleaded guilty to (whether or not resulting in a conviction); Pleaded “no contendere” or “no contest” to; Admitted to; Have had any judgment or order rendered against (whether by default or otherwise); Entered into any settlement of an action or claim of; Had any license, certificate of employment suspended, revoked, terminated of adversely affected because of; Been diagnosed as having or treated for any mental or emotional conflict arising from; Resigned under threat of termination of employment or volunteer work; FOR any allegation, any conduct, matter or thing (irrespective of the formal name thereof) constituting or involving (whether under criminal or civil law of any jurisdiction) in any of the following activities:Statements that apply Any felony Rape or other sexual assault Abuse of a minor or child, whether physical or sexual Incest Kidnapping, false imprisonment or abduction Sexual harassment Sexual exploitation of minor Sexual conduct with a minor Annoying/molesting a child Lewdness and/or indecent exposure Lewd and lascivious behavior Obscene literature Assault, battery or other offense involving a minor Endangerment of a child Any misdemeanor or other offense classification involving a minor or to which a minor was a witness Unfitness as a custodian of a minor Removing children from a state or concealing children in violation of a law or court order Restrictions of limitations on contact or visitation with children or minor Similar or related conduct, matters or things Been accused of any of the above. EXCEPT THE FOLLOWING: (If you left any of the statements above unsigned with your initials, please explain)DateDescription The above statements are true and complete to the best of my knowledge.Applicant’s Signature DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 GOOD SAMARITAN BOYS RANCH AUTHORIZATION TO RELEASE INFORMATION REGARDING AN EQUAL OPPORTUNITY EMPLOYERApplicant’s Name First Last Applicant's Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Applicant’s Social Security Number Agency Contact Person Authorization expiration dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I, the undersigned, authorize and consent to any person, form, organization, or corporation provided a copy (including photocopy or facsimile copy) of this Authorization to Release information by the above-stated agency to release and disclose to such agency any and all information or records requested regarding me including, but not necessarily limited to, my employment records, volunteer experience, military records, criminal information records (if any), and background. I have authorized this information to be released, either in writing or via telephone, in connection with my application for employment or to be a volunteer at the agency. Any person, form, organization, or corporation providing information or records in accordance with the Authorization is released from any and all claims or liability for compliance, such information will be held in confidence in accordance with agency guidelines. This authorization expires on the date stated above. Signature DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 GOOD SAMARITAN BOYS RANCH NOTICE OF PRE EMPLOYMENT MANDATORY URINE DRUG SCREENING*All new applicants are subject to a mandatory Urine Drug Screening as a pre-employment requirement. Employment will be contingent upon a negative Urine Drug Screening. Urine Drug Screening is done at Universal Screening Services no cost to the prospective employee. Prospective employees will need to go Universal Screening Services located at 549 S. Ingram Mill Road for specimen collection when indicated by the Ranch. The Employee may call to set an appointment at 417-831-1400. After employment has been secured at the Ranch, the employee will be subject to random Urine Drug Screening as determined by administration. The undersigned indicates they have read the above and understand the contents. Full Name DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 GOOD SAMARITAN BOYS RANCH PRE-EMPLOYMENT INQUIRY RELEASEIn connection with my application for employment (including contract for services) with you, I understand that investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my work performance and experience, along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil and other experiences, as well as claims involving me in the files of insurance companies. I authorize, without reservation, any party or agency contacted by this employer to furnish the above- mentioned information. I release any corporation and/or individual, including records custodians, from all liability for any damages that may result to me on account of compliance or any attempts to comply with this authorization. I have a right to make a written request within a reasonable period of time to receive additional detailed information about the nature and the scope of this investigation. I hereby consent to your obtaining the above information, including a credit and/or criminal report, from a credit reporting agency network, and agree that such information that the credit reporting agency network obtains and my employment history with you, will be accessible through you and the credit reporting agency network by future companies to which I might apply.Name First Last SSN: Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of birth Month Day Year Driver’s License Applicant’s Signature Date MM slash DD slash YYYY Prospective Employer: GOOD SAMARITAN BOYS RANCH P.O. Box 617 Brighton, MO 65617 *This information will not be used for purposes of discrimination. The Federal Age Discrimination Employment Act of 1967 prohibits discrimination based on age with respect to individuals who are at least 40. Request for InformationTo: Applicant: Name: Social Security Number Dates of Employment: Immediate Supervisor: Our agency Good Samaritan Boys Ranch, is requesting information regarding the above-mentioned applicant who is seeking a position. This agency serves children and youth, and accordingly, undertakes background investigations to determine whether the individual poses a risk of harm to those who would be served. We are interested in receiving any information or records that would reflect on the applicant’s fitness work with children and youth. Please complete the attached EMPLOYER DISCLOSURE AFFIDAVIT and return it to our agency at your earliest convenience. Although any information you wish to provide is welcomed, we are especially interested in any conduct, matter or things that involve established or a reasonable basis for suspecting physical, psychological or sexual misconduct with respect to children or youth. You may receive a separate written or telephone request from our agency for an employment reference regarding the applicant. Please respond to each request independently. With this request is an authorization executed by the applicant. This releases you from any liability for your reply, either in writing or via telephone. Thank you for your assistance.Failure by your agency or organization to provide information requested may result in automatic disqualification of the applicant. P.O. Box 617 Brighton, Missouri 65617 (417) 376-2238 Fax (417) 376-2014 www.ranchlife.org Proprietary and Confidential For GSBR Internal Use Only rev 09/24/13
