Employment Application
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
If applying for a specific position, list the job title here:
*
Total number of years experience:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
I meet the following requirements (check all that apply):
*
Passion for IDD/DD adults.
Basic computer skills
Clear criminal background
Reliable & prompt
Able to commit to job timeline
18+ years old
Can legally work in the U.S.
Current CPR/FA certification or willingness to renew
Have a Drivers License/State Issued ID
Positive Attitude
Are you authorized to work In The United States?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
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Employment Desired:
Date You Can Start
*
-
Month
-
Day
Year
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Salary Desired
*
Position Interested In (check all that apply):
*
Full Time
Part Time
Temporary
On Call
Experienced With:
*
Multiples
Special Needs
Allergies
Medically Fragile Adults
Assisting adults that are unable to control incontinence
Non Verbal Adults
Following a Daily Lesson Plan
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Skills/Qualifications:
List three words that describe your personality:
What skills and experience do you currently have, that may be useful in this position? Feel free to be as in depth as possible.
CPR/First Aid Certified?
Please Select
Yes
No
Willing to Get Certified
CPR/First Aid Expiration Date
-
Month
-
Day
Year
Name of CPR/FA instructor:
Phone number for CPR/FA instructor:
List any additional health & safety trainings:
Anything else you would like to share:
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Education:
Highest Level of Education:
Please Select
High School
College
Graduate School
High School
Name of High School Attended
Graduated High School?
Please Select
Yes
No
College
Name of College/University Attended
Graduated College?
Please Select
Yes
No
Number of Years Attended College
College Area of Study/Degree
Graduate School
Name of Graduate School Attended
Graduated Grad School?
Please Select
Yes
No
Number of Years Attended
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Graduated From Trade School?
Please Select
Yes
No
Number of Years Attended
Area of Study/Degree
List of other professional training:
i.e. STARS, NCS, Doula training, conference workshops, etc.
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Mandatory Job History
Current Employer Name
i.e. Name of Family
Current Employer Position
Your job title
Current Employer Salary
Current Employer Start Date
-
Month
-
Day
Year
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Current Employer Location
i.e. Neighborhood
Current Employer Duties
Please include an in-depth job description
Current Employer May We Contact?
Yes
No
Please explain why we may not contact your current employer:
Previous Employment
Previous Employer
i.e. Name of Family
Previous Employer Position
Your job title
Previous Employer Salary
Previous Employer Start Date
-
Month
-
Day
Year
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Previous Employer End Date
-
Month
-
Day
Year
Date Picker Icon
Previous Employer Location
i.e. Neighborhood
Previous Employer Duties
Please include an in-depth job description
Previous Employer Reason for Leaving?
Previous Employer May We Contact?
Yes
No
Please explain why we may not contact your previous employer:
Third Recent Employer
i.e. Name of Family
Third Recent Employer Position
Your job title
Third Recent Employer Salary
Third Recent Employer Start Date
-
Month
-
Day
Year
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Third Recent Employer End Date
-
Month
-
Day
Year
Date Picker Icon
Third Recent Employer Location
i.e. Neighborhood
Third Recent Employer Employer Duties
Please include an in-depth job description
Third Recent Employer Reason for Leaving?
Third Recent Employer May We Contact?
Yes
No
Please explain why we may not contact your third recent employer:
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References:
Please include at least three
May we contact your references?
Yes
No
Reference One
Name of Reference
Reference One Relationship
Reference One Years Acquainted
Reference One Phone
Reference One Email
example@example.com
Reference Two
Name of Reference
Reference Two Relationship
Reference Two Years Acquainted
Reference Two Phone
Reference Two Email
example@example.com
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Cover Letter & Resume:
Please Upload Your Cover Letter
Upload a File
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Choose a file
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Please Upload Your Resume
Upload a File
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Acknowledgement
I have uploaded my resume. Without a resume, I understand that my application may not be considered.
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