Provider Job Application

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Cross Streets:*

Phone Number*

Area CodePhone Number

E-Mail*

At Least 18 Years Old*

YesNo

Do You Have A Drivers License*

YesNo

Do You Have A Fingerprint Clearance Card*

YesNo

Do You Have CPR/First Aid*

YesNo

Do You Have Article 9*

YesNo

Are You A U.S. Citizen*

YesNo

Have You Ever Been Convicted Of A Crime*

YesNo

If yes, please Explain

Do You Have Reliable Transportation*

YesNo

Position That You Are Applying For*

Referred By*

Please Describe Referral Source*

Work History: Current and previous employer (most current employer listed first)

Most Recent Employer

City, State

Position Held

Start Date

MonthDayYear

Date Finished

MonthDayYear

Employer phone

Area CodePhone Number

Describe Your Duties:

Reason for leaving

NEXT EMPLOYER

Most Recent Employer

City, State

Position Held

Start Date

MonthDayYear

Date Finished

MonthDayYear

Employer phone

Area CodePhone Number

Describe your duties:

Reason for leaving

HIGH SCHOOL

Name & City/State of High School*

Did you graduate*

YesNoGED

COLLEGE OR UNIVERSITY

Name & City/State of College or University

Course of Study/ Degree Earned

Did you graduate

YesNoAttending

OTHER

Name & City/State of OTHER (specify)

Course of Study/ Degree Earned

Did you graduate

YesNoAttending

You should hire me because...*

I understand and agree that if hired my employment is "at will" and is not for a definate period and may, regardless of circumstances, be terminated at any time without prior notice by Acadia Care Group.

I acknowledge that as a condition of my employment, I will be required to agree to be bound by the terms of and sign the Company.

Failure to sign this Agreement shall result in revocation of my offer of employment.

HCBS Services, including Respite Care, Attendant Care and Habilitation Care, require at least three (3) months experience with individuals with disabilities.

By signing below, I understand and agree that I have at least three (3) months experience with individuals with disabilities.

Please indicate qualifying experience and / or training below:

Describe Here*

Date*

Date

Signature*

APPLICATION FOR EMPLOYMENT

GENERAL INFORMATION

JOB INTEREST

Employment History Information

EDUCATION INFORMATION