Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

How did you hear about us? (required)

Preferred method of contact? (required)

When is the best time to contact you? (required)

What position(s) are you applying for? (required)

Section 2 - Employment Verification

Are you over 18 years old? (required)

Yes No

If under 18, can you submit a work permit?

Yes No

Upon hire, can you submit verification of your identity and legal right to work in the United States? (required)

Yes No

Are you able to fulfill the responsibilities for this position as described in the job description? (required)

Yes No

If no, please describe any limitations and reasonable accommodations for these:

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Are you a veteran?

Yes No

Please note any skills, hobbies or interests relevant to serving adults with disabilities:

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Section 3 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and years attended (From/To)

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Please list other relevant courses completed

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Are you currently certified in First Aid? (required)

Yes No

Are you currently certified in CPR? (required)

Yes No

Please list specific medical conditions/disabilities that you have experience with, or have received training for. Give as much detail as possible.

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Section 4 - Other Training: Certifications/Licenses

Certifications/Licenses:

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Section 5 - Employment Information and Availability

What date are you available for employment? (required)

Are there periods of time that you absolutely CANNOT work? (required)

If the previous question did not adequately capture your availability, please give a detailed account of the times and days which you would not be available to work.

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Do you have reliable transportation to and from work, and for travel between worksites, if required? Use of public transportation is considered reliable transportation. (required)

Yes No

Can you provide documentation of a driver's license and auto insurance? (required)

Yes No

Drivers License Expiration Date:

Auto Insurance Expiration Date:

Have you previously applied for a position with Santa Cruz Supported Living? (required)

Yes No

When?

Have you worked for Santa Cruz Supported Living in the past? (required)

Yes No

When? Enter last date worked.

Do you have any friends/relatives working for Santa Cruz Supported Living? (required)

Yes No

If yes, please indicate who.

Why are you interested in working with people with disabilities in the community?

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Section 6 - Most Recent / Current Employment

Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

Yes No

Section 7 - 2nd Most Recent Employment

Last Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

Yes No

Section 8 - 3rd Most Recent Employment

Employer:

Address:

City:

State:

Zip:

Start Date:

End Date:

Hours Worked:

Position/Title

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

Section 9 - Professional Reference 1

Name: (required)

Company: (required)

Phone: (required)

Email:

Section 10 - Professional Reference 2

Name: (required)

Company: (required)

Phone: (required)

Email:

Section 11 - Professional Reference 3

Name: (required)

Company: (required)

Phone: (required)

Email:

Section 12 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

Relationship: (required)

Section 13 - Resume / Cover Letter

Cover Letter (Optional)

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Cut and Paste Resume Here (Optional)

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Section 14 - Applicant's Certifications and Agreements

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection of this application or immediate discharge if I am employed, regardless of time elapsed before discovery. (required)

Yes No

I hereby authorize Santa Cruz Supported Living to thoroughly investigate my references, work record, education, and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to Santa Cruz Supported Living any and all letters, reports and other information related to my work records without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure. (required)

Yes No

I understand that Santa Cruz Supported Living is an at-will employer and that accordingly nothing contained in the application, or conveyed to me during any interview, which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or Santa Cruz Supported Living, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s president. (required)

Yes No

Date of Application (required)

Name: (required)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature

Santa Cruz Supported Living Application Form

Personal Information

Section 1 - General Information

Section 2 - Employment Verification

Section 3 - Education

Section 4 - Other Training: Certifications/Licenses

Section 5 - Employment Information and Availability

Section 6 - Most Recent / Current Employment

Section 7 - 2nd Most Recent Employment

Section 8 - 3rd Most Recent Employment

Section 9 - Professional Reference 1

Section 10 - Professional Reference 2

Section 11 - Professional Reference 3

Section 12 - Emergency Contact Information

Section 13 - Resume / Cover Letter

Section 14 - Applicant's Certifications and Agreements