CDAVillage

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Application for Employment

This application form is intended for use in evaluating your qualifications for placement. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form, are grounds for terminating the application process, or if discovered after placement, terminating placement. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to placement.

APPLICANT INSTRUCTIONS: If you need help filling out this application form or with any phase of the placement process, please notify the person that gave you this form and every reasonable effort will be made to accommodate your needs.

Please answer each question.

Consistent with relevant law, the information on this application will not be disclosed to unauthorized persons.

Pay Range: $16-21, dependent on experience and education level.

APPLICANT INFORMATION

Date of Application

Position Applying For: (Direct Care Provider, etc.)

First Name

Last Name

Middle Name

Maiden Name

Have you used other names?

Other name used AND dates used:

Are you 19 or older? Type Yes or No.

Current Address

City

State

Zip

Previous Address with city, state and zip code:

255 character limit

0 / 255

Primary Phone Number

Secondary Phone Number

On what date would you be able to start work?

Driver's License #:

JOB RELATED SKILLS

Note: Do not fill out any part of this section you believe is non-job related. If you choose to disregard any question in this section, please briefly note your reasons.

I have been given a job description and understand the requirements of the position.

I am able to perform the requirements of this job with or without reasonable accommodations.

I have my own transportation.

License plate #

Auto Insurance Carrier:

Policy #:

If you answered no to the question about your own transportation, do you have access to transportation? Please describe:

Have you ever had any moving violations? Speeding ticket, failure to yield, etc. Please describe and give dates:

255 character limit

0 / 255

THREE PROFESSIONAL REFERENCES

Reference 1 Name

Reference 1 Phone Number

Reference 1 Relationship

Reference 1 Years Known

Reference 1 Address

Reference 2 Name

Reference 2 Phone Number

Reference 2 Relationship

Reference 2 Years Known

Reference 2 Address

Reference 3 Name

Reference 3 Phone Number

Reference 3 Relationship

Reference 3 Years Known

Reference 3 Address

PERSONAL REFERENCE

Personal reference name

Personal reference phone number

Personal reference relationship

Personal reference years known

Personal reference address

SECURITY

Please list all states and countries you have lived in since the age of 18 (most recent first):

State & Country most recent

State & country, 2nd most recent

State & country, 3rd most recent

Have you ever used any social security numbers other than given?

Other social security numbers used

EMPLOYMENT HISTORY

Identify all employers for whom you have worked in the last ten years. Include part-time and temporary employers. List your most recent employer first. “See Resume” is not an acceptable response.

Please describe your activities during any gaps in employment in the last ten years. Do not include leave or time off due to illness or medical treatment.

Employer Name 1

Employer 1 Supervisor Name

Employer 1 Address

Employer 1 Phone Number

Employer 1 Position Title and Duties

255 character limit

0 / 255

Employer 1 Start Date

Employer 1 End Date

Employer 1 Reason for Leaving

Employer 2 Name

Employer 2 Supervisor Name

Employer 2 Address

Employer 2 Phone Number

Employer 2 Position Title and Duties

255 character limit

0 / 255

Employer 2 Start Date

Employer 2 End Date

Employer 2 Reason for Leaving

Employer 3 Name

Employer 3 Supervisor Name

Employer 3 Address

Employer 3 Phone Number

Employer 3 Job Title and Duties

255 character limit

0 / 255

Employer 3 Start Date

Employer 3 End Date

Employer 3 Reason for Leaving

Employer 4 Name

Employer 4 Supervisor Name

Employer 4 Address

Employer 4 Phone Number

Employer 4 Job Title and Duties

255 character limit

0 / 255

Employer 4 Start Date

Employer 4 End Date

Employer 4 Reason for Leaving

Employer 5 Name

Employer 5 Supervisor Name

Employer 5 Address

Employer 5 Phone Number

Employer 5 Job Title and Duties

255 character limit

0 / 255

Employer 5 Start Date

Employer 5 End Date

Employer 5 Reason for Leaving

Employer 6 Name

Employer 6 Supervisor Name

Employer 6 Address

Employer 6 Phone Number

Employer 6 Job Title and Duties

255 character limit

0 / 255

Employer 6 Start Date

Employer 6 End Date

Employer 6 Reason for Leaving

Employer 7 Name

Employer 7 Supervisor Name

Employer 7 Address

Employer 7 Phone Number

Employer 7 Job Title and Duties

255 character limit

0 / 255

Employer 7 Start Date

Employer 7 End Date

Employer 7 Reason for Leaving

EDUCATION

Education

Graduation date of highest level of education

Degree, School Name & City/State

LICENSES, CERTIFICATION, AND SPECIAL SKILLS

Please identify all professional and other licenses or certifications you currently hold or have held previously:

Include type of license, license #, expiration date, issuing agency/school/etc.

255 character limit

0 / 255

Please list any other skills or qualifications that may be job related or that you feel would be of value to this organization:

255 character limit

0 / 255

Please list languages in which you are fluent:

Please list any hobbies, activities, or experiences that might provide skills or knowledge helpful to the position you seek:

APPLICANT'S STATEMENT

I hereby authorize all employers, organizations, and other entities and persons identified in this form to release any information contained in their files or records concerning me. Type Yes or No:

In consideration of the receipt and evaluation of this application by Children’s Village, I hereby release Children’s Village and any individual, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family on account of compliance or any attempts to comply with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

I HAVE CAREFULLY READ THE FORGOING RELEASE AND KNOW THE CONTENTS THEREOF, AND I SIGN THIS RELEASE AS MY OWN FREE ACT. Type Yes or No:

I understand and agree it is critical to Children’s Village that all employees conform to the highest standards of safety, interpersonal conduct, and sexual morality when clients or minors are involved. I affirm that I will strictly comply with Children's Village policies and procedures, including those concerning child safety and protection, sexual abuse and misconduct, and interpersonal relationships. I understand and agree that failure by me to abide by such policies and procedures may result in my immediate dismissal, or disciplinary action, all in the sole discretion of the Children's Village.

Type Yes or No

If hired, I understand my employment is at will and can be terminated at the discretion of Children’s Village or at my option, without notice, at any time, except as specifically set forth in writing in a current individual employment agreement, if any, which I have entered into with Children’s Village. Absent such a written employment agreement, I understand I will be an at will employee, if hired.

I understand employment is at-will. Type Yes or No:

I understand and agree that failure by me to abide by such policies and procedures may result in my immediate dismissal, or disciplinary action, all in the sole discretion of the Children's Village. Type Yes or No:

I understand no one can enter into agreement for me without written authority signed by CEO. Type Yes or No:

I understand this application is not an offer of employment and no promises or representations of employment have been made to me at this time. Type Yes or No.

My responses above are truthful and accurate. I understand and agree that if they are not truthful and accurate, Children’s Village, may determine that I am no longer qualified to be associated with its programs as an employee or volunteer. Type Yes No:

I consent and agree that Children’s Village may obtain a criminal background check upon me through a qualified department or division of law enforcement of the State of Idaho or any of its political subdivisions. Type Yes or No:

My typed name below is a representation of my legal signature and I hereby agree to sign in person in the office at Children's Village.

Today's Date

Availability:

We are a 24 hour residential home. What is your availability? The more open your availability, the higher the chance we can bring you in for an interview. If your availability is restricted to only certain days, the likelihood is low that we will be able to hire you.

Please include ALL shifts you are available to work, not what you prefer.

Full Time

Part Time

______________________________________________________

Day Shifts (6am-12pm/2pm)

Day Shift - Which days? Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday

24 (9am-9am)

24 Shift - Which days? Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday

Swing Shift (2pm-10pm)

Swing Shift - Which days? Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday

Overnight (10pm-6am)

Overnight - Which days? Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday

Evening Shift (4pm-9pm)

Evening Shift - Which days? Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday

Thank you for applying to join the Children's Village Team!