Employment Application

Prospective Employee,

Thank you for your interest in employment with Above and Beyond Care. Above and Beyond Care, Inc. is a non-profit Medicaid waiver provider. Our agency employs direct support professionals to provide in-home and in-community supportive living services for persons with developmental disabilities throughout the State of Arkansas. We make our best attempt to match professionals with consumers whom we believe they would work most effectively with. Please fill out the following application, in its entirety, and submit all required documentation promptly.

We look forward to reviewing your application and thank you for your interest in serving through our agency.

ABC Management Team

Date of Application:*

MonthDayYear
Date
Name:*

First NameLast Name
Birth Date:

MonthDayYear
Primary Number:*

Area CodePhone Number
Can we text this number?

YesNo
Secondary Number

Area CodePhone Number
Can we text this number?

YesNo
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Applying For:
Desired Rate of Pay:
Rate of pay is dependent on the reimbursement rate of the insurance of the client you work with, education, and experience.
How were you referred to us?*

Walk-InEmployeeRadio AdIndeedOther (please specify)
If other, please specify:
Please list name of employee who referred you (if applicable):

Other Considerations:
Are you employed elsewhere?
If yes, please specify name of other place of employment and current schedule:
Please list all DHS/DDS (Department of Human Services/Division of Developmental Disabilities Services) agencies you have worked for:
Are you related to any ABC client?
If yes, please specify name of client and nature of relationship:
Are you related to any ABC employee?
If yes, please specify name of employee and nature of relationship:
Would you consider a host-home arrangement, in which a member of the agency would reside in your home, given a paid rental agreement was in place?

Would you work overnight in another person's home?

Employment History

Please list all work experience for the past five (5) years. List a minimum of two previous places of employment.
Company:      Dates Employed:
Address:   Street Address   Address Line 2   City   State   Zip   Title/Position:      Supervisor:   First Name   Last Name   Area Code   Phone Number   Job Description:
Reason for Leaving:      Rate of Pay:
Company:      Dates Employed:
Address:   Street Address   Address Line 2   City   State   Zip   Title/Position:      Supervisor:   First Name   Last Name   Area Code   Phone Number   Job Description:
Reason for Leaving:      Rate of Pay:
Company:      Dates Employed:
Address:   Street Address   Address Line 2   City   State   Zip   Title/Position:      Supervisor:   First Name   Last Name   Area Code   Phone Number   Job Description:
Reason for Leaving:      Rate of Pay:
Company:      Dates Employed:
Address:   Street Address   Address Line 2   City   State   Zip   Title/Position:      Supervisor:   First Name   Last Name   Area Code   Phone Number   Job Description:
Reason for Leaving:      Rate of Pay:
Upload Resume:

Upload a File

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Job Skills, Education, and Training
Describe your skills:
Please list school(s) attended, degrees/diplomas conferred, and date(s) of conferral.
Training or Certifications:

References

Please list two (2) references that are familiar with your work life, not related to you, and whom you have known for at least one year.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Legal Considerations
Have you been convicted of a crime? Please indicate yes/no and provide explanation:*

Please assess the following hypothetical client scenarios and answer the questions to the best of your ability:
Jack is a 33-year old male who has been diagnosed with Intellectual Disability, Mild. Part of your job is to assist Jack in managing his finances. Jack refuses to pay his electric bill. What do you do?*
Maggie is non-verbal and has a diagnosis of Autism. You are at the mall when Maggie falls to the floor kicking, screaming, and biting her arm. How would you help her?*
You are a live-in staff for a 40-year old male with severe developmental disabilities. He is non-verbal and cannot make you aware of his wants/needs. He is crying, with his arms folded around his waist. What could this mean? What steps would you take to care for him?*
You are working with a 23-year old client who experiences seizures as a result of Epilepsy. They have had a seizure and fallen to the ground, becoming injured. What do you do?*

Please place a check by each option to indicate your knowledge and understanding of each employment requirement:*

I understand that this is a position in which I will be providing direct supports to an individual with one or more developmental disabilities.I understand that working on holidays may be required, as there is still a need to provide services to clients.I understand that to be eligible for employment, I must possess a valid AR driver's license, Proof of Insurability, and reliable transportation.I understand that this position is subject to initial and random drug screening, as required by the Department of Human Services and to ensure the well-being of our clients.I understand that this position requires Criminal, Child and Adult Maltreatment, and other background checks, as mandated by the Department of Human Services.
The following documents are required to process an application. Incomplete applications will not be processed. Documents can be faxed to our central office at (501) 213-0574 or scanned and emailed to timesheetsabc@gmail.com:

Authorization

I certify that the facts contained herein this application are true, complete, and accurate to the best of my knowledge. I understand that, if employed, falsified statements on this application or any attached document shall be grounds for dismissal. I also understand that by state law, I am required to submit to the following background checks: State Police, Central Registry for both Child and Adult Maltreatment. A subsequent employment offer shall be considered temporary pending the return of these background checks, along with verification of eligibility for employment. I understand that employment references will be checked.

I authorize investigations of all statement contained herein and all references and employers listed above to give you any and all information concerning my previous employment and pertinent information that may have, personally or otherwise, affected my past employment or have an expected impact on the position I am applying for now. I release the company from all liability for any damage that may result from utilization of such information.

I understand and agree that no representative of the company has any authority to enter into any agreement, for employment for any specified amount of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the American with Disabilities Act (ADA) and other relevant federal and state laws.
Applicant Signature*

Clear
Applicant Printed Name*
Date*

MonthDayYear
Date
Should be Empty: