List ALL Previous Addresses during the last five years
Type of Position(s) Preferred
Indicate which shifts you will accept
Indicate your desired employment status
Indicate Days and List Hours Available for Work
List any other education, training, specials skills, certificates/licenses that you possess which might be related to this job
List any work limitations that you may have and briefly describe
Client Types and Work Duties
Clients Not Willing/Able to Work With
Duties Not Willing/Able to Perform
Indicate which of the following you have experience in
Work Related - 1
Work Related - 2
2 nd to Last Position
Work Related - 3
3 rd to Last Position
Professional Reference - 1
Professional Reference - 2
Please read carefully before signing. Place a check mark in front of each paragraph, and sign below. If you have any questions regarding the following statements, please ask for assistance.
I certify that to the best of my knowledge and belief, the answers given by me to the foregoing questions and the statement made by me in this application are correct and complete. I understand that any false or incomplete information contained in this application may result in my discharge.
I understand that this agency serves people who are in need and as such, the agency may deem necessary that overtime hours or hours outside normally defined work day or work week may be required at times.
I understand that if You First Supported Living, LLC hires me, my employment status will be on an at-will basis. This means that either myself or a supervisor representative of the agency may terminate my employment with You First Supported Living, LLC at any time for any reason. Any statements, either implied or explicit, in writing or spoken, by anyone other than the Executive Director of the agency, regarding employment on a contractual basis will be viewed as null and void. Furthermore, I understand that my continued employment is based on the wishes of the consumer You First Supported Living, LLC serves, continued funding through local authorities and my ability to continue to appropriately perform the duties of the job as outlined in the job description.
I understand You First Supported Living, LLC is continually looking for qualified applicants. I also understand my application may not currently be a match for the placement the agency has available due to the hours I can work or the employment status for which I am looking, among other things. I understand my application will be kept active for a period of 45 days from the date of this application listed above.
I understand that due to State and Local regulations, You First Supported Living, LLC is required to initiate a criminal background check, motor vehicle record check, Abuser Registry and Nurse Aid Abuse checks, prior to employment to ensure eligibility in accordance with the above rules. I further understand that depending on the results of the aforementioned background checks, I may be ineligible for employment with You First Supported Living.
I authorize You First Supported Living, LLC (the Agency) to communicate with all my former employers, school officials and persons named as references. I also grant permission to the agency to obtain a motor vehicle operation record, and a criminal history record. I hereby release employers, schools, agencies, companies and individuals from any liability for any damaged whatsoever resulting from giving such information.
I certify that the facts and information provided by me on this application, on other pre-employment documents, and my employment interview are true and complete and I agree that, if employed; incorrect, incomplete of falsified information will be grounds for my dismissal, regardless of when discovered.