Employment Application New

GENERAL
POSITION APPLIED FOR:
OTHER TYPE OF WORK DESIRED:
SALARY REQUIRED:
DATE OF APPLICATION:
MM slash DD slash YYYY
TYPE OF EMPLOYMENT:
DATE AVAILABLE TO START WORK:
MM slash DD slash YYYY
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 * Required
Middle Name
Last Name * Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Email * Required
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, Max. file size: 10 MB.
Accepted file types: png, pdf, docx. PDF format preferred.
Maximum file size - 10 mega bytes.

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. * Required
- YES
- NO

Employment Application