We do not descriminate on the basis of race, color, religion, national origin, sex, age,or disability.  It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

Social Security Number:
Phone # *
Last Name *
First Name *
Middle Initial *
Street Address *
City *
State *
Zip Code *
Employment Desired:
What position are you seeking?
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Please indicated the job title for the position you are applying.
What pay do you expect?
Date available to work:
How did you learn about this position?


Are you 18 years of age or older? *
Are you interested in:


Have you applied here before? *
If yes, when?
Were you ever employed here?
If yes, when?
Are you presently employed? *
May we contact your present employer? *
Do you have relatives working here? *
If so, please give name and relationship:
Have you ever been convicted of any law violation, including any traffic violations? *
If yes, please provide details:

(A "yes" answer does not automatically disqualify you from employment.   The nature of the offense, date and the job for which you are applying will also be considered.)
Do you have a valid driver's license? *
Driver's License Number:
Class of license:
Has your driver's license been suspended or revoked in the last 3 years? *
If yes, give details:

Experience/Special Skills
List special skills and/or experiences you have had with individuals and/or families who have a disability. Please indicate the age group and the disability.
List equipment that you operate that may help qualify you for employment.
List certificates or licenses you hold, or specialized training you have completed that may help qualify you for employment.
List any foreign languages you speak, read or write and indicate proficiency (fluent, good, fair).
Education
High School or GED:
Number of years completed:
Diploma, degree, certificate:
Subjects studied:
College or University:
Number of years completed:
Degree, diploma or certificate:
Subjects studied:
Technical or Vocational:
Number of years completed:
Diploma, degree, certificate:
Subjects studied:
Can you, if employed, submit verification of your right to work inteh United States? *
Employment Experience

Start with your present or last job first.  Include any job-related military service assignments, volunteer activities and any periods of unemployment.  You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.  If self-employed, give firm name and provide business references.
Employer Name:
Employer Address:
Employer Phone #:
Dates of Employment:
Pay (indicate per hour, week, month, or year):
Job Title and Duties
2nd Employer Name
2nd Employer Address
2nd Employer Phone #:
Dates of Employment
Pay (indicate per hour, week, month or year):
Job Title and Duties:
3rd Employer Name
3rd Employer Street Address:
3rd Employer Phone #:
Dates of Employment
Pay (please indicate per hour, week, month or year):
Job Title and Duties
Personal References (other than relatives or current or past employers):
1st Reference Name:
1st Reference Address (include ZIP code):
1st Reference Phone #:
Years Known:
2nd Reference Name:
2nd Reference Address (include ZIP code):
2nd Reference Phone #:
Years Known:
2rd Reference Name:
3rd Reference Name:
3rd Reference Address (include ZIP code):
3rd Reference Phone Number:
Years Known:

I certify that all information provided in this application is true and complete.  I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications.  I understand that any investigation conducted may include a request for employment and educational history, credit reports, consumer reports, investigative consumer reports, driving record, and criminal history.  I authorize any person, school, current and former employer, consumer reporting agency, and any other organization or agency to provide information relevant to such investigation and I hereby release all persons and corporations requesting or supplying information pursuant to such investigation from all liability or responsibility to me for doing so.  I understand that I have the right to make a written request within a reasonable period of time for complete disclosure of the nature and scope of any investigation.  I further authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the job for which I am being considered or any future job in the event that I am hired.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME, IF EMPLOYED.  I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

I have read, understand, and by clicking the "Apply Now" button below, consent to these statements.

 

Please read statement carefully before applying.

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