CEDAR VALLEY COMMUNITY SUPPORT SERVICES

APPLICATION FOR EMPLOYMENT-Direct Care Professional

Thank you for your interest in our company, please answer all questions completely and truthfully.

GENERAL

Desired Start Date:     Employment Type:   Full TimePart Time

Desired Number of Hours:

Name (as it appears on Social Security card):

Physical Address:

Is your Mailing Address different than above?YesNo

Mailing Address:

Phone Number:   Phone Type:HomeCell

Email Address:  

Are you legally eligible for employment in the U.S.? (Verification will be required): YesNo

Are you of legal age to work in the U.S.?: YesNo

Have you ever been convicted by any law enforcement agency with the commission of any crimes? YesNo

EDUCATION

Did you graduate from high school?YesNo

Month and Year Graduated: 

Do you have your GED or High School Equivalent Certificate?YesNo

Month and Year Recieved: 

Last grade of school completed: 

Did you attend any other schools, colleges, or secondary education programs?YesNo

Program Information:

Did you graduate?YesNo

Did you attend any additional schools, colleges, or secondary education programs?YesNo

Program Information:

Did you graduate?YesNo

Did you attend any additional schools, colleges, or secondary education programs?YesNo

Program Information:

Did you graduate?YesNo

Did you attend any additional schools, colleges, or secondary education programs?YesNo

Program Information:

Did you graduate?YesNo

WORK HISTORY

Starting with the most recent employment, please give details of work experiences, including apprenticeships, summer work, miscellaneous jobs and volunteer work:

Does your employment history include at least one job?YesNo

Employer Information:

Current Employer?YesNo

Start Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Start Date:

End Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Employer Information:

Current Employer?YesNo

Start Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Start Date:

End Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Employer Information:

Current Employer?YesNo

Start Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Start Date:

End Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Employer Information:

Current Employer?YesNo

Start Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Start Date:

End Date:

Reason for Leaving:

May we contact for reference? YesNo

Add another Employer?YesNo

Employer Information:

Current Employer?YesNo

Start Date:

Reason for Leaving:

May we contact for reference? YesNo

Start Date:

End Date:

Reason for Leaving:

May we contact for reference? YesNo

Is there any condition (s) which would preclude you from performing the job functions of the position for which you are applying?
YesNo

Upload Resume (Optional):

Upload Cover Letter (Optional):

REFERENCES

Please Provide 3 Professional References:

1:

2:

3:

Please list any additional Educational/Training Certificates, Awards, or any other qualifications not previously covered in this application that you believe would be beneficial to obtaining this position:

I have hereby been informed, that Cedar Valley Community Support Services considers all applicants without regard to race, color, religion, sex, national origin, the presence of non-related medical conditions or disabilities, or any other legally protected status.AgreeDisagree

I declare the information provided by me to be, to the best of my knowledge and belief, accurate and truthful. I understand that any false statement(s) or omission of facts may result in immediate termination.
AgreeDisagree

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document. YesNo