Application Form

Go to INITIAL APPLICATION FORM link to print, fill out and return to us. Thank you.

INITIAL APPLICATION FORM

 

INITIAL APPLICATION FORM

Instructions: In order to work for an individual with Intellectual Disabilities & Elderly, an applicant must be willing to complete the specific timeline on hiring checklists must sign and complete the initial application forms. Please fill out and return to us. 

 

PERSONAL INFORMATION

First Name _________________Middle Name __________________Last Name _______________________

Suffix ____________Aliases _____________Sex   _______________Race _________Hair Color __________

Eye Color _______________Weight _____________Height ______________

Date of Birth _______________________________Email Address _________________________

Social Security #_______________________________________________

COMPLETE ADDRESS_____________________________________________________________

Phone Number ____________________Cell Phone________________________

HAVE YOU LIVE IN A DIFFERENT STATE/COUNTRY IN THE LAST 5 YEARS?

 

YES OR NO__________________________________________________ if yes where?

 

_____________________________________________________________

 

Please answer all the following questions truthfully and be willing to provide documentations to support your answers.

1. Are you eligible to stay permanently in the United States? ____ Yes ____No
2. Have you been accused of Abuse Neglect and Exploitation? ____ Yes ____No

IF YES, WHAT WERE YOU CHARGED WITH? _____________________________________________________________________

 

_____________________________________________________________________

IF THE CASE (you charged with) IS CLOSED CAN YOU PROVIDE A LETTER FROM THE DCF? ___ Yes ____No

3. Are you eligible to pass a local background check (Police Clearance) in your county where you live?   ____ Yes ____No
4. Have you done a Level 2 (Fingerprint) Background Check in the last five years?

____ Yes ____No

 

5. HAVE YOU EVER BEEN ARRESTED? ___ Yes ____No

 

6. IF YES, WHAT WERE YOU CHARGED WITH? _____________________________________________________________________

_____________________________________________________________________

IF THE CASE (you charged with) IS CLOSED CAN YOU PROVIDE A LETTER FROM THE COURT? ___ Yes ____No

 

7. ARE YOU WILLING TO TAKE DISABILITY TOPIC TRAINING IN ORDER TO HELP YOU UNDERSTAND PEOPLE YOU WILL SPEND TIME WORKING? Circle:   Yes   or   No

 

IF YES, PLEASE CHOOSE THE TRAINING THAT YOU WILL BE INTERESTED IN:

_______ Intellectual Disability (MR) ______ Autism

 

_______ Cerebral Palsy (CP)               ______ Spina Bifida

 

_______ Prader-Willi Syndrome           ______ Down Syndrome

 

8. ARE YOU CURRENTLY WORKING? Circle:   Yes   or   No   If Yes, where? _____________________
9. WHAT MAKES YOU WANT TO WORK TO PEOPLE WITH DEVELOPMENTAL DISABILTY/ELDERLY?

____________________________________________________________

____________________________________________________________

 

I certify that information contained in this form is true and complete. I authorize the verification of any or all information listed above.

 

____________________________________________________________

Signature                                                                                                         Date