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Developmental and Intellectual Disability Services
Personal Care
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Dementia Care
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Job Employment Form
Step
1
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4
25%
LinkedIn
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PERSONAL INFORMATION
First Name
(Required)
Last Name
(Required)
Date
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
State / Province
ZIP / Postal Code
Home Phone Number
Social Security Number
(Required)
Driver’s License / ID
(Required)
State
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Email Address
Have you ever applied for employment with this Agency?
Yes
No
How many days/hours a week are you available for work?
Are you legally eligible for employment in the United States?
Yes
No
What is your expected rate of pay for this position?
How did you learn of our organization?
Newspaper Ad
Agency Employee
Other
Are you willing to work
Evenings
Weekends
Position applying for
Educational Background
College / Graduate
School Name / Location
Major
Yrs of Study/Degree
Vo-Tech / Trade
School Name / Location
Major
Yrs of Study/Degree
High School
School Name / Location
Major
Yrs of Study/Degree
Others
School Name / Location
Major
Yrs of Study/Degree
EMPLOYMENT
List the last five years employment history, starting with the most recent employer.
Company Name
Telephone
Address
Date of Employment (Start)
MM slash DD slash YYYY
Date of Employment (End)
MM slash DD slash YYYY
Starting Pay
Ending Pay
Job Title and Describe Work Completed
Reason for leaving
Company Name
Telephone
Address
Date of Employment (Start)
MM slash DD slash YYYY
Date of Employment (End)
MM slash DD slash YYYY
Starting Pay
Ending Pay
Job Title and Describe Work Completed
Reason for leaving
Company Name
Telephone
Address
Date of Employment (Start)
MM slash DD slash YYYY
Date of Employment (End)
MM slash DD slash YYYY
Starting Pay
Ending Pay
Job Title and Describe Work Completed
Reason for leaving
Was your last name different from your present name during the above listed jobs?
Yes
No
If yes, what was your name?
Are you currently employed?
Yes
No
Do you have reliable transportation / the ability to reach multiple clients?
Yes
No
TWO (2) Professional / Personal Reference Check
Reference Full Name
(Required)
Phone
(Required)
City
(Required)
State
(Required)
Relationship to applicant
If Professional Reference: Position Held
Reference Full Name
(Required)
Phone
(Required)
City
(Required)
State
(Required)
Relationship to applicant
If Professional Reference: Position Held
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
Yes
No
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:
Are you capable of performing the job set forth in the job description?
Yes
No
If you answered No, which job requirement can you not meet?
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENTOPERATED
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.
I,
(Required)
authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.
I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time
Signature
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Date
(Required)
MM slash DD slash YYYY
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Email
Best Time to Call
Morning
Afternoon
Evening
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Facebook
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