Application for Employment Application for Employement Step 1 of 5 20% Programs, services, and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for the application or interview.Application Date:* MM slash DD slash YYYY Date Available to Start* MM slash DD slash YYYY Positions Applying For:* Transportation Staff Direct Support Staff (on-site) Direct Support Staff (HCBS) Buckeye Program Manager Please select the positions you would like your application to be considered for.How were you referred to us? Driver’s license number:* State* Applicant DataSalary RequirementPer hour or yearName* First Middle Last Jr/Sr./III Current Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Prior Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Alternate Phone NumberEmail Have you ever worked for Choices DTA?*–YesNoWhen did you last work for Choices DTA?* MM slash DD slash YYYY I am over 18 years of age and have the lawful right to work in the United States.*–YesNoAre you a citizen of the United Sates?*–YesNoIf you are not a US citizen and we require a work permit, can you furnish one?*–YesNoIf no, please explain:* What type of transportation do you use?* Personal Public/Bus Ride From a Friend Other Do you have any allergies?* Yes No List other allergies:List multiple allergies by clicking the plus button. Do you have any work restrictions?* Yes No Please explain you work restrictions:*Maximum lift in Pounds* What languages do you speak? What type of experience do you have?* Type of employment desired?* Full Time Part Time Seasonal AvailabilityDay Available Monday Tuesday Wednesday Thursday Friday Saturday From* : Hours Minutes AM PM AM/PM To : Hours Minutes AM PM AM/PM Time of Day Available Morning Afternoon Evening Have you ever plead guilty or been convicted of a criminal offense, other than a minor traffic violation?*–YesNoIf yes, when?* MM slash DD slash YYYY Where?* Please provide details:*Answering “yes” to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be considered. Educational DataHighest Education Level Achieved?* High School Diploma GED College Trade School CNA Certified Caregiver LPN Other Other* Degree Obtained: AAS BA MA Other Discipline Year Certifications: CPR/First Aid Art-9 CIT Medications Fingerprint Clearance Other Other Certifications* Employment HistoryPlease complete your previous employment history (begin with most recent position):Dates of Employment:* MM slash DD slash YYYY Position(s) Held:* Firm:* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Supervisor Name:* Supervisor's Title:* Responsibilities:* Starting Salary:* Starting Title:* Ending Salary:* Ending Title:* Reason for leaving:* May we contact this employer as a reference?*–YesNoDo you have additional work experience?*Choose AnswerYesNo Dates of Employment: MM slash DD slash YYYY Position(s) Held: Firm: Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSupervisor Name: Supervisor's Title: Responsibilities: Starting Salary: Starting Title: Reason for leaving: Ending Title: May we contact this employer as a reference?–YesNo I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, and other related matters as may be necessary for an employment decision. I hereby authorize employers, institutions, schools, and/or individuals to release any requested information to Choices Day Treatment Centers and release all from liability when responding to inquiries in connection with my application. In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge. In good faith of the above, I hereby type my full name to signify my electronic signature and submit my application for review. Type Full Name to Sign* Δ
