DSP Application form

Direct Support Professional (DSP) Part Time
All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status, or any other protected classification, in accordance with applicable federal, state, and local laws. By completing this application, you are seeking to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our customers and contributing to the financial success of the organization, its clients, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring accommodation to complete the application and/or interview process should contact a management representative.
Positions applied for
Date of application

MonthDayYear
Date
Full name
Address

Street address

Street Address Line 2

CityState

ZIP
Main phone number
Alt phone number
Email
example@example.com
Employment Experience

Please list the names of your present or previous employers in chronological order with the present or most recent employer listed first. Be sure to account for all periods of time. If self- employed, give the firm name and supply business references. Add an additional page if necessary.
1. Name of employer
Supervisor
May we contact?

YesNo
Street address
Phone number
Dates Employed from: (month/year)
From (month/year)
Dates Employed To: (month/year)
To (month/year)
Job Title
Job duties
Reason for leaving
2. Name of employer
Supervisor
May we contact?

YesNo
Street Address
Phone number
Dates Employed from: (month/year)
from (month/year)
Dates Employed To: (month/year)
To (month/year)
Job title
Job duties
Reason for leaving
3. Name of employer
Supervisor
May we contact?

YesNo
Street Address
Phone number
Dates Employed From: (month/year)
From (month/year)
Dates Employed To: (month/year)
To (month/year)
Job title
Job duties
Reason for leaving
Have you ever been involuntarily terminated or asked to resign from any job?

YesNo
If yes please explain
Please explain any gaps in your employment history
Please list any other experience, job-related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment
Education

Please describe your educational background below.
High School
Diploma/Degree (yes/no)
Area of study/major
Specialized training, skills, or extracurricular activities
College / University
Diploma / degree (yes/no)
Area of Study/major
Specialized training, skills, or extracurricular activities
Graduate / Professional School
Diploma / Degree (yes/no)
Area of Study / major
Specialized training, skills, or extracurricular activities
Trade School
Diploma / Degree (yes/no)
Area of Study / major
Specialized training, skills, or extracurricular activities
Other (School Name)
Diploma / Degree (Yes/No)
Area of study/Major
Specialized training, skills, or extracurricular activities
Business and Professional References

Please list three professional references of individuals who are not related to you.
1. Name and Title
Relationship
Phone number or email
2. Name and title
Relationship
Phone number or email
3. Name and title
Relationship
Phone number or email
Personal References

Please list three people who know you well.
1. Name and Title
Relationship and years acquainted
Phone number or email
2. Name and title
Relationship and years acquainted
Phone number or email
3. Name and title
Relationship and years acquainted
Phone number or email
General Information
Have you ever used another name?

YesNo
Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?

YesNo
If yes to either of the above, please explain
Have you ever worked for this company before?

YesNo
If yes please provide dates and position
Do you have friends and/or relatives working for this company?

YesNo
If yes, name(s) and relationship(s)
On what date are you available to begin work?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Are you available for work?

Full timePart timeShift workTemporary
If hired, would you have reliable means of transportation to and from work?

YesNo
Can you travel if the position requires it?

YesNo
Are you at least 18 years of age?

YesNo
Note:

If under 18, hire is subject to verification that you are of minimum legal age.
If hired, can you present evidence of your identity and legal right to work in this country?

YesNo
Are you able to perform the essential job functions of the job for which you are applying with or without reasonable accommodation?

YesNo
Note:

We comply with the Americans with Disabilities Act and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.
I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the company any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.
Your initials
In the event of my employment with the company, I understand that I am required to comply with all rules and regulations of the company.
Your initials
If hired, I understand and agree that my employment with the company is at will and that neither I nor the company is required to continue the employment relationship for any specific term. I further understand that the company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.
Your initials
I understand that the safety of employees is extremely important to the company and that the company is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health.
Your initials
I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Your initials
I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration law requires me to complete an I-9 Form in this regard.
Your initials
I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable.
Your initials
My signature attests to the fact that I have read, understand, and agree to all of the above terms.
Signature

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Full Name
Date

MonthDayYear
Date
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Direct Support Professional (DSP) Part Time

Business and Professional References

Personal References

General Information

Note:

Note:

My signature attests to the fact that I have read, understand, and agree to all of the above terms.