Employment Application

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*
Zip Code*
Phone*
Social Security Number*
Driver License Number / State*
Referred By
Are you 18 years of age or older?*
- Yes
- No
Have you ever been substantiated for abuse or neglect?*
- Yes
- No
If “yes”, please explain:
Have you ever been convicted of a crime?*
- Yes
- No
If “yes”, please explain:*
Do you have your own car, a valid Driver’s License and full automobile insurance?*
- Yes
- No
(Please note that positions require transporting clients)
Have you had any motor vehicle violations in past 3 years?*
- Yes
- No
If “yes”, please explain
For which position are you applying?
- Direct Support Professional (DSP)
- Personal Care Attendant (PCA)
- Other (please explain)
Please Explain
If responding to an internet job posting (ie. Craigslist, Careerbuilder, etc), please indicate "job posting reference id"
Salary Desired
Per
Schedule Desired
- Full Time
- Part Time
Shift
Indicate days of week you can work
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
What date could you start work?
Date Format: MM slash DD slash YYYY

EDUCATION
High School
School Name
City and State
Degree or # of Years Completed
Did you graduate?*
- Yes
- No
If no, do you have a GED?*
- Yes
- No
College
School Name
City and State
Degree or # of Years Completed
Major or Subject
Did you graduate?*
- Yes
- No
Graduate, Trade, Business, or Correspondence School
School Name
City and State
Degree or # of Years Completed
Major or Subject
Did you graduate?
- Yes
- No
List 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*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
May We Contact Your Employer*
- Yes
- No
Previous Employer
Address
Phone
Position Title
Supervisor's Name and Title
Reason for Leaving
Nature of the position
Salary
Per
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
May We Contact Your Employer
- Yes
- No
Previous Employer
Address
Phone
Position Title
Supervisor's Name and Title
Reason for Leaving
Nature of the Position
Salary
Per
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
May We Contact Your Employer?
- Yes
- No
Please 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 1
Name*
First Last
Phone*
Relationship*
Years Known*
Additional References
(NOT RELATED TO YOU AND NOT PREVIOUSLY LISTED)
Name*
First Last
Phone*
Relationship*
Years Known*
Reference 3
Name*
First Last
Phone*
Relationship*
Years Known*
Reference 2
Please 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*
Date Format: MM slash DD slash YYYY