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Apply for Job

Part Time Direct Care Staff/ Weekends (8:00pm-8:00am). (Now Hiring)

First name *

Middle name*

Last name*

Social Number*

Address and Apartment *

City

State

Zip/Postal Code

Country *

Home Phone No.

Mobile Phone No.

Email Address

Are you authorized to work in the United States?

TRAINING AND EDUCATION

Colleges/ Other Training	Major/ Subject	Degree/ Certificates

ADDITIONAL SKILLS

SKILL	YES/NO	YEARS OF EXPERIENCE
Working with People with Disabilities
Computer Skills, Writing Skills, Documentation Skills
Patient Care
Working with Behavior Clients

Are you authorized to work in the United States? Proof of Authorization will be required post hire

BACKGROUND INFORMATION

EACH CASE IS CONSIDERED SEPARATELY BASED ON JOB DUTIES AND PERFORMANCE AREAS

Do you have a valid Florida Driver's License?

Other State

Provide Copy

(If position applied for involves driving), have you been convicted, pleaded to no contention or paid a fine for any traffic violations in the past three (3) years?

If yes please explain:

Have you been convicted of a felony or served time in prison within the last ten (10) years?

If yes please explain:

How/where did you hear about the position for which you are applying?

Please specify

EMPLOYMENT HISTORY

Beginning with your present or most recent employment, list your employment history. Include self-employment, military service, volunteer experience and periods of unemployment. The following sections MUST be completed even if a resume is submitted.

Employer *

Employed from*

To*

Address: *

Supervisor *

Phone *

Hours worked/week*

Starting salary*

Position *

Last salary *

Primary duties

Number of employees supervised by you *

May we contact this employer*

Supervisor's phone*

Reason for leaving

Employer *

Employed from*

To*

Address: *

Supervisor *

Phone *

Hours worked/week*

Starting salary*

Position *

Last salary *

Primary duties

Number of employees supervised by you *

May we contact this employer*

Supervisor's phone*

Reason for leaving

Employer *

Employed from*

To*

Address: *

Supervisor *

Phone *

Hours worked/week*

Starting salary*

Position *

Last salary *

Primary duties

Number of employees supervised by you *

May we contact this employer*

Supervisor's phone*

Apply for Job

Part Time Direct Care Staff/ Weekends (8:00pm-8:00am). (Now Hiring)

Are you authorized to work in the United States?

TRAINING AND EDUCATION

HIGHEST GRADE COMPLETED: 8 9 10 11 12 GED

ADDITIONAL SKILLS

Are you authorized to work in the United States? Proof of Authorization will be required post hire

BACKGROUND INFORMATION

EACH CASE IS CONSIDERED SEPARATELY BASED ON JOB DUTIES AND PERFORMANCE AREAS

(If position applied for involves driving), have you been convicted, pleaded to no contention or paid a fine for any traffic violations in the past three (3) years?

If yes please explain:

Have you been convicted of a felony or served time in prison within the last ten (10) years?

If yes please explain:

How/where did you hear about the position for which you are applying?

Please specify

EMPLOYMENT HISTORY

Beginning with your present or most recent employment, list your employment history. Include self-employment, military service, volunteer experience and periods of unemployment. The following sections MUST be completed even if a resume is submitted.

Primary duties

Reason for leaving

Primary duties

Reason for leaving

Primary duties

Reason for leaving