Employment Application
In Home

Programs, services and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for the application or interview.

Date of Application (Month/Day/Year):     	     /     /     	

Applicant Data

Position Applied for: ___________________________     
How were you referred to us: __________________________________________     

Full Name: ___________________________________________________     
Address:	     	   City:	     	State:	     	
Zip:	     		

Phone:	(   )      	Mobile/Pager/Other:	     		

E-mail: ______________________________     
Date Available to Start:	     	Social Security No.:	     	

Salary Requirement: _____________________________________     

Number of years’ experience with the intellectually disabled:  ____________ 
Paid experience or volunteer experience: _____________________

If you are under 18 and we require a work permit, can you furnish one?	    	Yes	    	No		
If no, please explain:	     	

Have you ever worked for this company?	   	Yes	   	No			
If yes, when?	     	

Are you a citizen 
of the United States?	    	Yes	    	No		

If not, are you 
legally allowed to 
work in the United States?	    	Yes	    	No		

Type of employment desired?	     	

Have you ever pleaded “guilty,” “no contest,” or been convicted of a crime for which you have not received a pardon.	   	Yes	   	No	

If yes, give dates and details:	     	

Answering “yes” to these questions does not constitute an automatic rejection for employment. Date of the offensive, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

Driver’s license number if applicable to position:	     	
State:	     		

Summarize Your Special Skills or Qualifications:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
     

Previous Employment (begin with most recent position):

Dates of Employment:	From	     	To	     		
Position(s) Held:	     		
Firm:	     	Address:	     	
Phone:	(   )      			
Supervisor:	     	Title:	     	
Responsibilities:	     	
		
Starting Salary 

and Title:	     	Ending Salary 

and Title: ____	     	
Reason for Leaving:	     	
May we contact this employer for a reference?	    	Yes	    	No		

Dates of Employment:	From	     	To	     		
Position(s) Held:	     		
Firm:	     	Address:	     	
Phone:	(   )      			
Supervisor:	     	Title:	     	
Responsibilities:	     	
		
Starting Salary 
and Title:	     	Ending Salary 
and Title:	     	
Reason for Leaving:	     	
May we contact this employer for a reference?	    	Yes	    	No		

Dates of Employment:	From	     	To	     		
Position(s) Held:	     		
Firm:	     	Address:	     	
Phone:	(   )      			
Supervisor:	     	Title:	     	
Responsibilities:	     	
		
Starting Salary 
and Title:	     	Ending Salary 
and Title:	     	
Reason for Leaving:	     	
May we contact this employer for a reference?	    	Yes	    	No		

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial and other related matters as may be necessary for an employment decision. I hereby release employers, schools or individuals from all liability when responding to inquiries in connection with my application. 

In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in termination of my employment for cause. 

Signature of Applicant:		Date: