Application
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Date of Application
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
-
Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Last four of Social Security Number
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XXX-XX-####
Format: xxx-xx-0000.
Email
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example@example.com
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Do you have a driver's license?
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Yes
No
I take the bus.
I have outsourced transportation.
Drivers License/ State ID Information
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DL#, State issued, and expiration date
Have you had any accidents in the last 3 years?
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If yes, how many and when?
*
If the answer is no, please record N/A
Have you had any moving violations in the last 3 years?
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If yes, how many and when?
*
If the answer is no, please record N/A
What position are you interested in?
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Please Select
First Available: (Based on what's available)
Direct Care Specialist: (Provide compassionate and individualized support to individuals with developmental disabilities, fostering their independence and enhancing their quality of life through daily activities and personal care.)
Personal Care Assistant: (Assist clients with developmental disabilities and elderly individuals in daily living activities, ensuring their comfort, safety, and overall well-being while promoting dignity and independence.
Adult Day Service Employee:
Facilitate engaging and meaningful activities for participants with developmental disabilities and older adults in a structured day program, promoting socialization, skill development, and community integration.)
Office Staff: (Support the administrative functions of programs serving individuals with developmental disabilities and the elderly by managing schedules, coordinating services, and maintaining accurate records to ensure efficient operations.)
***If unsure please select first available***
Desired salary?
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Employment desired:
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PART TIME ONLY (25 hours or less)
FULL TIME ONLY
FULL OR PART TIME
How many hours can you work?
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Less than 20
More than 20
Weekends Only
Can you work nights?
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Yes
No
Some
When would you be available to start?
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Month
-
Day
Year
Date
What hours and days can you commit to working?
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Sunday through Saturday start and end time.
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Type of School you have completed? (select all)
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High School (Diploma or GED)
College
Business or Trade School
Professional School
None of the above
School Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Major and Degree
If applicable
Number of years completed
Have you ever been convicted of a crime?
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Yes
No
If yes, please explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently, sentence(s) imposed, and type(s) of rehabilitation.
Have you ever been in the Armed Forces?
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YES
NO
Are you now a member of the National Guard?
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YES
NO
If yes, Specialty/ Date Entered/ Discharge Date?
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Previous Work History
*MUST PROVIDE AT LEAST 2 PAST EMPLOYERS*
Company
*
Company Name
Job Title
Start Date
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Month
-
Day
Year
Date
End Date
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Description and reason you left.
*
Company
*
Company Name
Job Title
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Description and reason you left.
*
Company
Company Name
Job Title
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Description and reason you left.
Company
Company Name
Job Title
Start Date
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Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Description and reason you left.
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Please Upload your Resume to complete your application! Thank you for you interest in joining our Team with Complete Care Supported Living Service Agency LLC.
Signature
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Please select an available Interview Appointment Slot!
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