If you prefer, you may download the application, print, and submit it via mail.

Download Employment Application Form

Applicants will be considered only for one (1) or at the most (two) specific jobs based on a single application.  This application will be held in the active file for sixty (60) days.  After that period, if you still wish to be considered, please contact us.

To Process your application, all questions must be answered.

General Information

1) Phone:
1) Phone Type
2) Phone:*
2) Phone Type:
Are you known to schools or other references by another name:*
List other names:*
Position applied for:*
Position type:
Salary / Hourly rate requirements:*
Salary Type:
Rank in order of preference the type of work you desire. 1 through 3 with 1 being the most desired.*
Please list the days and hours you are available for work (Days / Hours):*
Date available to work:*
How or by whom were you referred to us?
Have you applied with us before?*
Are you over 18 years of age?*
Are you legally eligible to work in this country? (If you are hired, you must provide proof of authorization to work in the United States.)*
Have you ever been convicted of a felony, misdemeanor, or any offense other than a minor traffic violation? (Convictions will not necessarily disqualify you from employment.)*
Please explain: *
Do you have an appropriate valid driver’s license?*
State Driver’s License Number:*
Have you ever been ticketed for a moving violation?*
Have you ever been denied a license, permit, or privilege to operate a motor vehicle?*
Has any license, permit or privilege ever been suspended or revoked?*
Please explain and YES responses from the previous three questions:*

Accident record for the past three (3) years.

If  None, write NONE.

Most Recent Accident First then Next Previous, etc.

1) Dates, Nature of Accident (Head-on, Rear-end, etc.), Fatalities, Injuries
2) Dates, Nature of Accident (Head-on, Rear-end, etc.), Fatalities, Injuries
3) Dates, Nature of Accident (Head-on, Rear-end, etc.), Fatalities, Injuries
4) Dates, Nature of Accident (Head-on, Rear-end, etc.), Fatalities, Injuries

Employment Record Section

Start with the Present or Most Recent employer, List all previous employers. Include self-employment, military service, summer and part-time jobs.

1) Present/Previous Employer

Present/Previous Employer Company Name:
Present/Previous Employer Address:
Present/Previous Employer Phone:
Present/Previous Employer Start Date:
Present/Previous Employer End Date:
Present/Previous Employer Starting Salary:
Present/Previous Employer Ending Salary:
Present/Previous Employer Positions & Duties:
Present/Previous Employer Name & Title of Supervisor:
Present/Previous Employer. May we contact this employer?

2) Next Previous Employer

Previous Employer (#2) Company Name:
Previous Employer (#2) Address:
Previous Employer (#2) Phone:
Previous Employer (#2) Start Date:
Previous Employer (#2) End Date:
Previous Employer (#2) Starting Salary:
Previous Employer (#2) Ending Salary:
Previous Employer (#2) Positions & Duties:
Previous Employer (#2) Name & Title of Supervisor:
Previous Employer (#2). May we contact this employer?

3) Next Previous Employer

Previous Employer (#3) Company Name:
Previous Employer (#3) Address:
Previous Employer (#3) Phone:
Previous Employer (#3) Start Date:
Previous Employer (#3) End Date:
Previous Employer (#3) Starting Salary:
Previous Employer (#3) Ending Salary:
Previous Employer (#3) Positions & Duties:
Previous Employer (#3) Name & Title of Supervisor:
Previous Employer (#3). May we contact this employer?
Additional Employment History:
If presently employed, why do you wish to change your position?
Account for all periods of unemployment of one (1) month duration or more since you left school to the present. Include date range and state what you were doing during the period.

Education Section

High School

High School Name:
High School or Prep Address:
High School or Prep Major Course or Subject:
High School or Prep Number of Years Completed:
High School or Prep Degree:
High School or Prep Grade Point Average:

Business or Trade School

Business or Trade School Name:
Business or Trade School Address:
Business or Trade School Major Course or Subject:
Business or Trade School Number of Years Completed:
Business or Trade School Degree:
Business or Trade School Grade Point Average:


College Name:
College Major Course or Subject:
College Address:
College Number of Years Completed:
College Degree:
College Grade Point Average:

Graduate Work

Graduate Work Name:
Graduate Work Degree:
Graduate Work Address:
Graduate Work Major Course or Subject:
Graduate Work Number of Years Completed:
Graduate Work Grade Point Average:
If you did not graduate, why and when did you leave school or college?
List scholastic honors, offices held, and activities in high school or college. Do not list organizations which reveal race, creed, color, national origin, religion, age or sex.
List any courses you have completed which aid this Agency in evaluating your qualifications for the position you are seeking. Example: If applying for a clerical, job coach or supervisory position, note training such as word processing, human services, or supervisory training. Please include grade or other indicator of achievement, such as a certificate. (Course, Date Enrolled, School, Describe Course Content, Grade)
Are you planning to pursue further studies?*
Check all that apply:
When, where, and what course (s):

Use this space below to describe skills and aptitudes that you feel qualify you for a position at the Agency.  You may wish to include civic and community activities, professional societies in which you participate, hobbies, sports, special trainings or skills such as booking, work processing, sales, customer communications, operation of equipment, or other applicable skills.  Please do not list organizations or activities which reveal race, religion, age, sex, national origin or ancestry, sexual orientation, disability or political persuasion.  List only organizations that you consider relevant to your ability to do the job for which you are applying.

Skills and Aptitudes:

Reference Section

Please list references other than previous employers, supervisors, or relatives. Providing this information means you give this Agency permission to contact those individuals listed. Name, Address, Telephone Number.

This Agency is an equal opportunity employer and does not discriminate in its hiring or employment practices on the basis of race, color, religion, age, sex, national origin or ancestry, marital status, or status within any other group protected by applicable federal, state or local nondiscrimination laws.  No questions on this application are intended to secure information to be used for such discrimination.

By signing your name below, you acknowledge and certify:

  • that all statements made by me on this application are true and complete to the best of my knowledge.
  • that I have withheld nothing that would affect this application unfavorable.
  • that any offer I may receive from the Agency is contingent upon my successful completion of the Agency’s total pre-employment screening process.
  • that I understand that misrepresentations or omissions may be caused for rejection, or may be cause for subsequent dismissal if I am hired.

I also understand that nothing contained in this application or in the interview process is intended to create an employment contract between the Agency and myself.  Should this application result in my employment, it will be an at-will relationship.  I have the right to terminate my employment at any time and for any reason and the Agency retains the same right.  I agree to conform to the rules and regulations of the Agency.  I further understand that no representative of the Agency other than the Executive Director of the Agency has any authority to enter into any agreement with me for any specified period of time or to guarantee some other personnel move or benefit.  I also understand that any such agreement, if mad, shall not be enforceable unless it is in writing and signed by me and the Executive Director.

I understand that past employers/educational institutions and/or the military will be contacted for references and I authorize any such organizations to provide the requested information.  I further release and forever discharge the Agency, its agents, its employees, and the individuals and companies contacted by the Agency as part of its inquiries and investigations, form any and all claims, demand, damages, actions, causes of action, or suits of any kind or nature whatsoever arising from the Agency’s inquiries and investigation of my credentials and information in connection with my application.

I further understand this entire statement applies to the period prior to, or after, I may be employed.

I hereby acknowledge that I have read and understand each of the above statements.  I authorize release of information about me to this Agency.

Lie Detector Statement


Direct Care Job Duties Acknowledgement

I understand that the position I am applying for requires the following:

  • Lifting (Ex. changing, toileting, transferring, positioning of individuals or for other work related activities)
  • Pushing (Ex. wheelchairs, pallet jacks)
  • Squatting / bending (Ex. Tie shoes, secure wheelchairs)
  • Driving (Ex. Daily runs, outings, coverage)
  • Flexibility (Ex. Working varied hours, days (including holidays and weekends), and other locations)
I affirm I can complete the job duties listed above.*
Submit Verification:

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