Better Together Mesa LLC
Employment Application
APPLICANT INFORMATION
Position Applying For:
*
Residential Youth Care Professional
Administration
Maintenance Team
Other
Name
*
First Name
Last Name
Social Security Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at current address?
*
Years
Months
Please provide previous addresses if less than 5 years of Arizona residency
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years at location
Years
Months
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years at Location
Years
Months
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
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Number of years experience working with youth?
*
Explain this experience (where/with who)
*
Group Home Experience?
*
Yes
No
If yes, what agency?
Privacy Respected
Do you have any criminal charges within the last 7 years?
*
Yes
No
If yes, please explain
Please check all that apply to your personal and legal history
*
Convicted of a Felony
DUI or DWI
Current suspended license
Unable to work with children
Smoke cigarettes
Smoke marijuana
Use any form of Drugs
Drink Alcohol
Health Conditions
Taking prescription Medication
Not Applicable
If yes, please explain
Please check all documentation that you currently possess
*
Fingerprint Clearance Card
CPR
First Aid
CPI Training
Health Assessment Training
College Diploma or Credits
AZ driver's license
Auto Insurance
Physical (within 2 years)
TB Test (within 2 years)
Form 1083
Notarized Criminal Self-Disclosure Affidavit
UPLOAD ALL DOCUMENTATION CHECKED ABOVE
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Availability (check all that apply)
*
Mon-Fri 3pm-11pm
Mon-Fri 11pm-7am
Weekend Days
Weekend Nights
Entire Weekend Shift
Gender
*
Male
Female
Other
Current/Previous Employer
*
Managers Name
*
First Name
Last Name
Managers Phone Number
*
Format: (000) 000-0000.
Start Date
*
-
Month
-
Day
Year
Date
End Date
*
-
Month
-
Day
Year
Date
EDUCATION
Name of Last School Attended
*
Highest Grade Level Completed
*
Please Select
High School Diploma
GED
Associates Degree
Bachelor's Degree
Master's Degree
Higher than Master's Degree
4 REFERENCES NEEDED WITH 2 YEARS WORTH OF WORK EXPERIENCE
Reference #1 Name
*
First Name
Last Name
Reference Job Title
*
Company Name
*
Valid Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Relation
*
coworker, supervisor, personal friend, etc...
Your Job Description (if work related reference)
Date Started (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Date Finished (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Reference #2 Name
*
First Name
Last Name
Reference Job Title
*
Company Name
*
Valid Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Relation
*
coworker, supervisor, personal friend, etc...
Your Job Description (if work related reference)
Date Started (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Date Finished (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Reference #3 Name
*
First Name
Last Name
Reference Job Title
*
Company Name
*
Valid Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Relation
*
coworker, supervisor, personal friend, etc...
Your Job Description (if work related reference)
Date Started (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Date Finished (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Reference #4 Name
*
First Name
Last Name
Reference Job Title
*
Company Name
*
Valid Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Relation
*
coworker, supervisor, personal friend, etc...
Your Job Description (if work related reference)
Date Started (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Date Finished (if work related reference)
-
Month
-
Day
Year
Date Picker Icon
Medical Information
Medical Condition
Rows
Excellent Condition
Satisfied
Needs Improvement
Poor Condition
Medical Assistance Needed
Vision
Hearing
Dental
Physical Condition
Any Surgeries, Special Needs, or Conditions
*
Yes
No
If yes, Please explain
Any Distinguishing Marks, Scars, or Tattoos?
Emergency Contact
Emergency Contact's Name
*
First Name
Last Name
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
Date Picker Icon
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