Employment Application Step 1 of 4 25% PERSONAL INFORMATION:(Part 1)Which Community Choice office/region you applying to?* Kansas City area St. Louis area First Name*Middle*Last Name*Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*Phone*Social Security Number*Driver License Number / State*Referred ByAre you 18 years of age or older?*YesNoHave you ever been substantiated for abuse or neglect?*YesNoIf “yes”, please explain:Have you ever been convicted of a crime?*YesNoIf “yes”, please explain:*Do you have your own car, a valid Driver’s License and full automobile insurance?*YesNo(Please note that positions require transporting clients)Have you had any motor vehicle violations in past 3 years?*YesNoIf “yes”, please explainFor which position are you applying? Direct Support Professional (DSP) Personal Care Attendant (PCA) Other (please explain) Please ExplainIf responding to an internet job posting (ie. Craigslist, Careerbuilder, etc), please indicate "job posting reference id"Salary DesiredPerHourWeekYearSchedule Desired Full Time Part Time ShiftFirstSecondThirdIndicate days of week you can work Sunday Monday Tuesday Wednesday Thursday Friday Saturday What date could you start work? EDUCATIONHigh SchoolSchool NameCity and StateDegree or # of Years CompletedDid you graduate?*YesNoIf no, do you have a GED?*YesNoCollegeSchool NameCity and StateDegree or # of Years CompletedMajor or SubjectDid you graduate?*YesNoGraduate, Trade, Business, or Correspondence SchoolSchool NameCity and StateDegree or # of Years CompletedMajor or SubjectDid you graduate?YesNoList any certificates earned or in progress, and/or any additional training programs not included in your formal education (i.e, CPR, First Aide, Medication Aide, CPI/MANDT) PREVIOUS EMPLOYMENT List your current or most recent employment first. Include work related internships, military and volunteer work.Current Employer*Address*Phone*Position Title*Supervisor's Name and Title*Reason for Leaving*Nature of the Position*Salary*Per*HourWeekMonthYearlyStart Date* End Date* May We Contact Your Employer*YesNoPrevious EmployerAddressPhonePosition TitleSupervisor's Name and TitleReason for LeavingNature of the positionSalaryPerHourWeekMonthYearStart Date End Date May We Contact Your EmployerYesNoPrevious EmployerAddressPhonePosition TitleSupervisor's Name and TitleReason for LeavingNature of the PositionSalaryPerHourWeekMonthYearStart Date End Date May We Contact Your Employer?YesNoPlease list any Organizations that provide support to people with disabilities or at risk children/adolescents that you have worked for that are not listed above: Reference 1Name* First Last Phone*Relationship*Years Known*Additional References (NOT RELATED TO YOU AND NOT PREVIOUSLY LISTED)Name* First Last Phone*Relationship*Years Known*Reference 3Name* First Last Phone*Relationship*Years Known*Reference 2Please list any reasonable accommodations that you would require to perform the essential functions of the position as stated in the Job Description*TELL US A LITTLE ABOUT YOURSELF, AND WHY YOU WOULD BE GOOD IN THIS POSITION*Applicant’s Signature: (I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.)*I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. Today's Date* This iframe contains the logic required to handle AJAX powered Gravity Forms.