EMPLOYMENT ELIGIBILITY Do you have a valid Drivers License?*
Do you have a safe and reliable vehicle?*
Do you have valid auto insurance?*
Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?*
How did you hear about us?*
Why are you interested in employment with us?*
What date are you available to begin work?*
Check times you are available to work:*
Check days you are available to work:*
List cities you are willing to work in.*
Please indicate the types of services which you are willing to provide:*
Describe any training or life skills you have that apply to providing services for adults with developmental disabilities:*
What do you like (or think you would like) most about working with adults with developmental disabilities?*
Check the highest level of education completed. NOTE: Minimum GED Requirement.*
Degree Earned*
Most Recent Employer Name and Address*
1. Job Title*
1. Dates Employed: From - To*
1. Supervisors Name / Phone Number*
1. Hourly Rate*
1. Reason For Leaving*
Second Most Recent Employer Name and Address*
2. Job Title*
2. Dates Employed: From - To*
2. Supervisors Name / Phone Number*
2. Hourly Rate*
2. Reason For Leaving*
Due to the nature of this work, you must be able to pass a background check, as it will be conducted. As a condition of employment all employees must be “Insurable”. Are you at least 18 years of age?*
Are you authorized to work in the US for any employer?*
Have you been charged/convicted of a felony and/or misdemeanor/or served time?*
If you answered "Yes" to the above question, please describe incident, city, state and charge or indicate N/A*
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?*
REFERENCE 1 Name / Phone / Address / Relationship (Do not include relatives)*
REFERENCE 2 Name / Phone / Address / Relationship (Do not include relatives)*
REFERENCE 3 Name / Phone / Address / Relationship (Do not include relatives)*
