Employment Application

Applicant Information
Applicant Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years at this address*
Daytime Phone
Evening Phone
Birth Date
MM slash DD slash YYYY
Social Security Number*
Driver's License (State/Number)*
Email Address*
CO-Applicant
CO-Applicant name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of years at this address
Daytime Phone
Evening Phone
Birth Date
MM slash DD slash YYYY
Social Security Number
Driver's License (State/Number)
Email Address
Emergency Contact

Who should be contacted if you are involved in an emergency?
Contact Name
First Last
Relationship to you
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime Phone
Evening Phone
Job Position Applied For
Have you applied to our company previously?*
- Yes
- No
If yes, when?*
Are you at least 18 years old?*
- Yes
- No
Are you willing to work any shift, including nights and weekends?*
- Yes
- No
If no, please state any limitations
If applicable, are you available to work overtime?
- Yes
- No
If you are offered employment, when would you be available to begin work?
Are you legally eligible for employment in the United States?*
- Yes
- No
Are you able to perform the essential functions of the job position with or without reasonable accomodation?
- Yes
- No
What reasonable accommodation, if any, would you require?
Applicant’s Skills

Rate those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)
Typing
Rating
Years
Microsoft Office Suite
(Word, Excel, etc.)
Rating
Years
Answering Telephones
Rating
Years
Filing
Rating
Years
Customer Service
Rating
Years
Applicant Employment History

List your current or most recent employment first.
Employer Name
Supervisor Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Duties
Reason for Leaving
Dates of Employment (Month/Year)
Employer Name
Supervisor Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Duties
Reason for Leaving
Dates of Employment (Month/Year)
Employer Name
Supervisor Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job Duties
Reason for Leaving
Dates of Employment (Month/Year)
Applicant’s Education and Training
College/University Name and Address
Did you receive a degree?
- Yes
- No
If yes, degree received:
High School/GED Name and Address
Did you receive a degree?
- Yes
- No
Certifications

Specify states of registration and license number. (please include copies of each as applicable: CPR, First Aid, Medical Certification, Crisis Intervention, CNA, etc.)
Other Training (graduate, technical, vocational)
Awards, Honors, Special Achievements
Military Service
- Yes
- No
Branch
Specialized Training
What would you not allow in your home?
- Smoker
- Alcohol
- Behaviors
- Ambulatory
- Non-Ambulatory
- Pets
- Sex offender
- Wheelchair
- Deaf or Blind
- Medical fragile
- Other
If "other" checked
Information about the host home Independent contract setting
Please list all members of your household:
Name Relationship Age
Briefly describe your home
Make note of special features that would be of assistance to you in providing services in the Host Home Program.(list such things as wheelchair accessibility, special amenities such as spare rooms, fenced yard, recreational areas, etc.)
Please list total number of rooms. Include how many rooms, bedrooms and bathrooms.
Please indicate the number and location of any fire extinguishers, smoke and carbon monoxide detectors in your home.
Do you have an operable phone in your home?
Do you own pets or livestock? If yes, please provide information.
Do you have reliable transportation?
- Yes
- No
What is your experience with the DD population?
Driver's License(s) and Proof of Insurance
Drop files here or

Max. file size: 50 MB.
Please attach copies of the driver’s licensed and proof of insurance to be used for transportation for all persons who will be transporting the people you serve. NOTE: prior to providing transportation, a motor vehicle record check must be completed prior to anyone in the HHP setting transporting the people you serve.
Homeowners/Renters Insurance
Max. file size: 50 MB.
Please attach copies of your homeowners/renters insurance overage
Company Name
Policy Number
References
Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Name
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Please provide any other information that you believe should be considered:
CAPTCHA

Name	Relationship	Age

Applicant Information

CO-Applicant

Emergency Contact

Applicant’s Skills

Typing

Microsoft Office Suite

Answering Telephones

Filing

Customer Service

Applicant Employment History

List your current or most recent employment first.

Applicant’s Education and Training

Certifications

Information about the host home Independent contract setting

References