The information I have given in this application is, to the best of my knowledge, accurate and truthful. I understand that falsifying this application is grounds for disqualification from consideration or termination if employed.

PLEASE READ AND SIGN THIS FORM

Valley Residential Services maintains that an alcohol and drug-free workplace is necessary for the safety of clients, employees, and the general public. VRS recognizes alcohol and drug dependency as an illness and a major health problem. However, the presence of alcohol and/or drugs in the workplace constitutes a safety risk and will not be tolerated.

Employment with VRS will be contingent upon the satisfactory result of a drug test before hiring. All employees may be subject to random alcohol/drug testing without cause. The cost of testing will be paid by the agency. All results will be held strictly confidential.

This policy is not intended to violate individual rights. It is intended to provide for an alcohol and drug-free environment that promotes safety and enhances the performance of the responsibilities assigned to employees. A complete copy of the VRS drug-free workplace policy is available at the administrative office.

IF YOU DO NOT WANT TO TAKE THIS PRE-EMPLOYMENT TEST YOU SHOULD WITHDRAW YOUR APPLICATION.

I hereby give my consent to any doctor, technician, hospital, VRS manager, or testing laboratory to conduct the required drug testing (including my giving of a urine specimen) and to have the drug test results be released to Valley Residential Services.

Valley Residential Services intend to employ the most suitable qualified persons available. The tenure of every employee shall depend upon the need of the work performed, the availability of funds, effective performance, good conduct, and continuing fitness for the position. Each employee shall be expected to perform at an optimal level.

Equal opportunity employment will assure that no appointment, promotion, dismissal, or discipline affecting any position in the agency shall be influenced negatively because of race, color, creed, religion, national origin, age, gender, presence of any sensory, mental or physical disability, including HIV/AIDS conditions, use of a trained guide dog or service animal by a person with a disability, marital status, disability status or Vietnam era status, sexual orientation, gender identity/presentation, or any other reason prohibited by law.

Valley Residential Services will provide qualified applicants and employees with disabilities with reasonable accommodations that do not impose an undue hardship.

If you believe you have been discriminated against you may file a complaint with the Valley Residential Services Affirmation Action Officer or contact an Equal Employment Opportunity Commission field office by calling 1-800-669-3362.

Valley Residential Services has my consent to contact my previous employers and personal references.

I certify, under penalty of perjury that the foregoing information is true, complete, and correct. I understand that any omission or misstatement of fact may be cause for dismissal from the position for which I am applying.

The information on this form is requested so that this agency can maintain compliance with the Non-discrimination Plan of the State of Washington.

This information will be used for recordkeeping and reporting requirements for the administration of civil rights laws and regulations.

Completion of this form is voluntary. Should you choose not to furnish this information, the agency will make a “visual inventory” to obtain data.

No adverse action will result from failure to furnish the requested information.

This information will be kept confidential and separate from personnel files.

Data will be available only to a civil rights complaint investigator. Otherwise, the data will be released only in a summarized version and will not identify any specific individual.

I hereby authorize Valley Residential Services to request information relating to my background. I understand that such inquiry may be to federal and/or state law enforcement agencies, that I will be notified of each response, and that a copy of each response will be available to me upon request.

I attest, under penalty of perjury, that the information I have provided on the attached Disclosure Statement is true and accurate to the best of my knowledge.