Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Email * Address * Social Security Number * Available Start Date * MM DD YYYY Position Applied For Desired Pay $ Employment Desired * Full Time Part Time Occasional/PRN/On-Call Live-in/Shared Living Family Caregiver Are You Legally Eligible To Work In The US? * Yes No Have you ever worked for this Employer? * No Yes Have you ever been convicted of a Felony? * No Yes Radio * I understand that abuse of any DD individual is a serious crime Yes No Radio * I understand that neglect of any DD individual is a serious crime Yes No Education * HS Diploma/GED College Degree Current CPR/First Aid DODD Initial DSP Training Current Med Cert 1 Current Med Cert 2 Current Med Cert 3 Trauma Informed Care De-Escalation Training Ohio Distracted Driving List up to 3 References. At least 1 should be Professional. Include name, Relationship, phone number, email, * Are you a Veteran? * No Yes Background Check Consent * Background Checks are required by law for any position, including family, volunteer or occasional, who will have contact with any client. I understand that I MUST complete a Background check prior to Hire Date and that the results must be received within 60 days Type Full Name for electronic signature * By typing my name as electronic signature, I am certifying that the information provided above is true and accurate. Thank you!