Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Are you 18 years or older?
*
Are you legally authorized to work in the US?
*
Are you vaccinated against COVID-19?
*
Employment Desired:
*
DSP
QIDP
Any
Date you can start?
*
MM
DD
YYYY
Are you employed now?
*
If currently employed, may we inquire of your present employer?
*
High School Education:
*
Did you graduate?
College Education:
Did you graduate?
Trade, Business, or Correspondence School:
Did you graduate?
Former Employer #1
*
Please provide the date you were hired:
MM
DD
YYYY
Former Employer #1
*
Please provide the last date of employment. Use today's date if still employed at that location.
MM
DD
YYYY
Former Employer #2
*
Please provide the date you were hired:
MM
DD
YYYY
Former Employer #2
*
Please provide the last date of employment:
MM
DD
YYYY
Former Employer #3
*
Please provide the date you were hired:
MM
DD
YYYY
Former Employer #3
*
Please provide the last date of employment:
MM
DD
YYYY
Reference #1
*
What is your acquaintance:
Reference #2
*
What is your acquaintance:
Reference #3
*
What is your acquaintance:
Skills Related to the Position:
*
Please describe any skills or connections you have in relation to advocacy, education, training, and/or support of individuals with intellectual challenges and/or developmental disabilities.
Statement of Accuracy and Truth
*
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.
I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.
