Employment Application New

GENERAL

POSITION APPLIED FOR:

OTHER TYPE OF WORK DESIRED:

SALARY REQUIRED:

DATE OF APPLICATION:

TYPE OF EMPLOYMENT:

DATE AVAILABLE TO START WORK:

HOW DID YOU HEAR ABOUT US?

"OTHER" REFERRAL SOURCE

STATE THE NAMES OF ANY FRIENDS OR RELATIVES, EXCLUDING A SPOUSE, CURRENTLY EMPLOYED BY BRIDGES: One name per line

HAVE YOU EVER BEEN EMPLOYED BY BRIDGES?

POSITION HELD/DATES

REASON FOR LEAVING:

PERSONAL DATA

First Name

Middle Name

Last Name

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email

Cell Phone

Home Phone

ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.?

IF ANY RECORDS ARE UNDER ANY NAME OTHER THAN SHOWN, PLEASE INDICATE:

DO YOU HAVE A DRIVER’S LICENSE? If yes, please be prepared to produce your license during the interview.

Gender

Ethnicity

HAVE YOU EVER BEEN A MEMBER OF THE ARMED FORCES OF THE UNITED STATES?

IF YES, PLEASE INDICATE BRANCH:

DATE OF SERVICE:

SPECIAL TRAINING OR EXPERIENCE RELATED TO THE POSITION FOR WHICH YOU ARE APPLYING:

HAVE YOU HAD ANY PRIOR OR CURRENT EXPERIENCE AS AN EMPLOYEE, VOLUNTEER, OR CERTIFIED PROVIDER WITH OPWDD OR OMH; ANY OTHER STATE AGENCY; OR ANY OTHER PROVIDER OF HUMAN SERVICES?

HAVE YOU HAD ANY PRIOR OR CURRENT EXPERIENCE IN CHILD-CARE?

HAVE YOU HAD ANY PRIOR OR CURRENT EXPERIENCE IN DIRECT CARE WORK?

HAVE YOU EVER BEEN EXCLUDED FROM PARTICIPATION IN ANY FEDERALLY SPONSORED HEALTH CARE PROGRAMS, INCLUDING BUT NOT LIMITED TO, MEDICAID AND MEDICARE?

PLEASE PROVIDE THE NAMES, ADDRESSES AND TELEPHONE NUMBERS OF REFERENCES WHO CAN VERIFY EACH EXPERIENCE: One per line

CRIMINAL RECORD

HAVE YOU EVER BEEN CONVICTED OF OR ARE YOU AWAITING TRIAL DISPOSITION ON A FELONY, MISDEMEANOR OR SUMMARY OFFENSE IN ANY JURISDICTION AND/OR DO YOU HAVE ANY PENDING CRIMINAL CHARGES, ARRESTS, OR CRIMINAL ACCUSATIONS AGAINST YOU?

CONVICTIONS WILL NOT AUTOMATICALLY DISQUALIFY JOB CANDIDATES. Date of conviction and severity will be considered.

IF YES, INCLUDE A DESCRIPTION OF ALL CONVICTIONS AND PENDING CRIMINAL CHARGES. STATE NATURE OF OFFENSES, WHEN, WHERE, AND DISPOSITION:

MOTOR VEHICLE DRIVING CERTIFICATION AND RECORD OF CONVICTIONS

DRIVER’S LICENSE AND DRIVING RECORD DISCLOSURE

Within the past three (3) years, have you had any convictions for moving violations, or have you had your driver’s license suspended or revoked? Please also indicate whether you have had any alcohol- or drug-related driving offenses, convictions for driving while intoxicated (DWI/DUI), or any driving-related occurrence involving injury to a person or damage to property.

DRIVING RECORD DISCLOSURE:

No Yes

IF YES, PLEASE PROVIDE THE DATE(S), NATURE OF THE VIOLATION OR OCCURRENCE, AND A BRIEF EXPLANATION:

EDUCATION

Please provide the name and location.

HIGH SCHOOL

GRADUATED

YEARS ATTENDED

TYPE OF DEGREE

COLLEGES UNIVERSITIES: Include field of study after the institution

GRADUATED

YEARS ATTENDED

TYPE OF DEGREE

VOCATIONAL SCHOOLS One per line

GRADUATED

YEARS ATTENDED

CERTIFICATE OR LICENSES

OTHER RELATED HISTORY/ACTIVITIES/SKILLS

STATE PROFESSIONAL LICENSES AND WHERE REGISTERED, VOLUNTEER EXPERIENCE OR ANY OTHER SPECIAL TRAINING OR SKILLS YOU HAVE THAT RELATE TO THE TYPE OF SERVICES OUR AGENCY PROVIDES:

EMPLOYMENT RECORD

List most recent jobs first.

EMPLOYER

ADDRESS

FROM

TO

JOB TITLE

SUPERVISOR

TELEPHONE NUMBER

SALARY

REASON FOR LEAVING

DUTIES PERFORMED

MAY WE CONTACT AT THE PRESENT TIME?

IF NOT, INDICATE WHEN:

EMPLOYER

ADDRESS

FROM

TO

JOB TITLE

SUPERVISOR

TELEPHONE NUMBER

SALARY

REASON FOR LEAVING

DUTIES PERFORMED

MAY WE CONTACT AT THE PRESENT TIME?

IF NOT, INDICATE WHEN:

ATTACH RESUME IN Accepted file types: png, pdf, docx. PDF format preferred.

BUSINESS-PERSONAL REFERENCES AND RELEASE

BUSINESS REFERENCES: Please list all past or current immediate supervisors.

BUSINESS NAME AND ADDRESS

IMMEDIATE SUPERVISOR’S NAME AND TITLE

PHONE NUMBER & EXTENSION

BUSINESS NAME AND ADDRESS

IMMEDIATE SUPERVISOR’S NAME AND TITLE

PHONE NUMBER & EXTENSION

PERSONAL REFERENCES: Please provide two personal references, including teachers, neighbors, and volunteer organizations.

NAME AND ADDRESS

ORGANIZATION NAME OR RELATIONSHIP TO APPLICANT

PHONE NUMBER & EXTENSION

NAME AND ADDRESS

ORGANIZATION NAME OR RELATIONSHIP TO APPLICANT

PHONE NUMBER & EXTENSION

APPLICANT CERTIFICATION

I hereby state that all the information that I provided on this application or any other document submitted in connection with my employment, and in any interview, are true and correct.

By selecting YES, the applicant certifies that the information provided is accurate and acknowledges that any false answers are grounds for dismissal.:

YES NO

Employment Application

GENERAL

PERSONAL DATA

CRIMINAL RECORD

DRIVER’S LICENSE AND DRIVING RECORD DISCLOSURE

EDUCATION

OTHER RELATED HISTORY/ACTIVITIES/SKILLS

EMPLOYMENT RECORD

BUSINESS-PERSONAL REFERENCES AND RELEASE

APPLICANT CERTIFICATION

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Employment Application

GENERAL

PERSONAL DATA

CRIMINAL RECORD

DRIVER’S LICENSE AND DRIVING RECORD DISCLOSURE

EDUCATION

OTHER RELATED HISTORY/ACTIVITIES/SKILLS

EMPLOYMENT RECORD

BUSINESS-PERSONAL REFERENCES AND RELEASE

APPLICANT CERTIFICATION

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