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
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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: K123456789101112
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
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
End Date:
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