CSI - Employment Application

Employment Application
Position Applying For:*
Date of Application*

MonthDayYear
Date
Are you able to perform the essential functions of the position for which you are applying with or without reasonable accommodation?*

YesNo
PERSONAL INFORMATION
Name*

First NameMiddle NameLast Name
Cell/Message Number*
Home Telephone Number/Or Cell*
Address*

Street Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Email*
example@example.com
Emergency Contact Name/Relation*
Telephone Number*
Applicant Date of Birth*

MonthDayYear
Date
Applicant Social Security Number*
PROFESSIONAL QUALIFICATIONS
Are you first-aid and CPR certified? *

YesNo
Do you have a valid driver’s license? *

YesNo
Do you have proof of current vehicle insurance? *

YesNo
Do you have a reliable vehicle? *

YesNo
Have you completed an application with us before? *

YesNo
If Yes, approximate date of previous application

MonthDayYear
Date
Have you ever been employed with us before? *

YesNo
If Yes, approximate dates of employment

MonthDayYear
Date
Have you had a background check with the Idaho Department of Health and Welfare within the last 2 years?*

YesNo
Do you have experience working with adults with developmental disabilities? *

YesNo
Describe your experience working with adults with developmental disabilities.*
What do you enjoy (or think you would like) most about working with a developmentally delayed adult?*
EMPLOYMENT HISTORY (Begin with the most recent)
Company Name*
Dates (From or Started)*

MonthDayYear
Date
Dates (To or Ended)*

MonthDayYear
Date
City. State*
Titles and Duties*
What liked most about this position is*
What dislike most about this position is*
Reason for Leaving*
Supervisor's Name*
Telephone Number*
EMPLOYMENT HISTORY
Company Name*
Dates (From or Started)*

MonthDayYear
Date
Dates (To and Ended)*

MonthDayYear
Date
City. State*
Titles and Duties*
What liked most about this position is*
What dislike most about this position is*
Reason for Leaving*
Supervisor's Name*
Telephone Number*
EMPLOYMENT HISTORY
Company Name
Dates (From or Started)

MonthDayYear
Date
Dates (To or Ended)

MonthDayYear
Date
City. State
Titles and Duties
What liked most about this position is
What dislike most about this position is
Reason for Leaving
Supervisor's Name
Telephone Number
EDUCATION/TRAINING
Have you obtained a: *

High School DiplomaGED CertificateNeither
Name of High School or GED/City/State*
Year Graduated or GED*
MILITARY

Higher Education - Fill Out Information Below:

	Name and Location	Diploma/Degree	Subject of Specialization
College/University
Vocational School /Tech or Specialized Courses & Training

Branch of Service
Describe any military training received relevant to the position for which you are applying
OTHER SPECIAL SKILLS, CERTIFICATES, OR TRAINING
List other specific skills, certificates or training you have
HISTORY (A criminal history in itself does not necessarily disqualify an applicant from employment). Have you ever been arrested, cited, held, detained, or charged with a felony regardless of whether the charge was dropped, dismissed, plea bargained or found not guilty?*

YesNo
If answering “Yes”, please explain and indicate which year of charge.
Have you ever been arrested, cited, held, detained, or charged with a misdemeanor regardless of whether the charge was dropped, dismissed, plea bargained or found not guilty?*

YesNo
If "Yes" please explain:
PREFERENCES (Give the names of three persons not related to you.)

	Name of Employer	Address	Telephone	Occupation
Employer Reference
Character Reference
Character Reference

HOW DID YOU HEAR ABOUT CSI?*

CSI WebsiteCraigslistCurrent/Past EmployeeOther
If from "Current/Past Employee" Name
Employee Scheduling

Coordinated Services of Idaho provides Residential Habilitation (ResHab) Services. We love working with adults with developmental disabilities, including those on the autism spectrum, those with mild intellectual disabilities, and those who have been served before in Certified Care Homes or Intermediate Care Facilities. Most of our clients live on their own. We provide one on one support to help individuals with their daily living. Hourly services are scheduled based on the goals, needs and hours of the participant.

We don't fill just to fill a position; we really try to match staff with clients and vise-versa to build long term relationships with our participants and staff. Schedules can be flex if client's goals and needs are met first.

While the agency makes every effort to accommodate the employee's preferences, the agency reserves the right to schedule/place employees as needed. When possible, the agency will attempt to give reasonable notice of changes in an employee's schedule or placement.
Are you interested in full time or part time? *

FTPT
Number of hours a week desired?*
Are you available for day shifts? *

YesNo
Are you available for split shift AM and early PM? *

YesNo
My first choice of shift is
Date available to start work?*

MonthDayYear
Date
Desired rate of pay?*
EMPLOYMENT AVAILABILITY (Be real and list your hours. Dream schedule so to speak. (Does not mean we can accommodate).
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
My preferred days off are
GEOGRAPHIC PREFERENCES (Indicate ALL areas you are willing to travel to work by marking the "YES" box.)

Coeur d Alene (Yes)Post Falls (Yes)Athol (Yes)Spirit Lake (Yes)Rathdrum (Yes)Sandpoint (Yes)
My first choice of geographic preference Is
PARTICIPANT CHARACTERISTICS
Are you willing to work with male participants? *

YesNo
Are you willing to work with female participants?*

YesNo
Are you willing to work with participants who have emotional behaviors or manipulative? *

YesNo
Are you willing to work with participants who may require hands on assistance with activities of daily living? *

YesNo
Are you willing to work with participants who may require some physical assistance? *

YesNo
Are you willing to work with participants who own pet? *

Cat: YesNo
Dog*

YesNo
or No Pets
Are you willing to provide transportation to help participants in the community? *

YesNo
To be able to provide transportation or run errands you will be required to have a valid driver's license and current auto insurance A motor vehicle check will be conducted and proof of insurance will be required CSI Does provide miles reimbursement. in accordance with client's plan.
EMPLOYEE OVERALL PREFERENCE
The most important preference factor is: *

ShiftDays offGeographic preferenceParticipant characteristics
EMPLOYMENT ELIGIBILITY STATEMENT

Coordinated Services of Idaho is an equal opportunity employer. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status that is protected by applicable federal, state, or local law.

As a condition of employment, all potential employees must provide proof of eligibility to work in the United States. This can be done by submitting documentation such as a U.S. passport, permanent resident card, or employment authorization card, and filling out I-9 Form.
ACKNOWLEDGEMENTS AND SIGNATURE

Must Type your name to acknowledge
I, * , understand that receipt of this application does not imply employment and is not a content of employment. This application form is intended for use in evaluating my qualifications for employment with Coordinated Services of Idaho.

I certify that the statements and information furnished by me in this application are true, complete, and correct to the best of my knowledge. I understand that any false information is ground for refusal to hire and if employed, cause for immediate dismissal. I authorize investigation of all information contained in this application for employment as may be necessary in arriving at an employment decision.

I certify that I have never been convicted nor have employment history of child or client abuse, neglect, exploitation or any other mistreatment with the company This is done as required by the state of Idaho's Department of Health and Welfare.

I understand that Coordinated Services of Idaho is a drug free workplace and that I subject to random drug testing for reasonable suspicion.

I understand this application for employment shall be considered active for period not to exceed 60 days. Any application wishing to be considered for employment beyond this period should inquire as to whether or not applications are being accepted at that time.

I acknowledge that my employment with this agency is at-will, meaning that either the Employer or the Employee may terminate the employment relationship at any time, with or without cause, unless otherwise defined by applicable law. I understand that no written document or conduct can conduct can modify this at-will employment relationship unless specifically acknowledged in writing by an authorized executive of Coordinated Services of Idaho, LLC.

The signature below certifies that I have read and agree with the above statements.
Signature*

Clear
Date*

MonthDayYear
Date
Agency Verification
Date

MonthDayYear
Date
Should be Empty:

PERSONAL INFORMATION

PROFESSIONAL QUALIFICATIONS

EDUCATION/TRAINING

MILITARY

OTHER SPECIAL SKILLS, CERTIFICATES, OR TRAINING

PREFERENCES (Give the names of three persons not related to you.)

PARTICIPANT CHARACTERISTICS

EMPLOYEE OVERALL PREFERENCE

ACKNOWLEDGEMENTS AND SIGNATURE