If you want to be part of our family, you may submit your application by filling out the form below. 


Your Name


Your Email


Your Address


Date of Birth (MM-DD-YYYY)

MM-DD-YYYY


How did you hear about us?


Position Applied for:


Desired  Monthly Salary


Have you ever worked for the MR/ DD population before?


Can you legally work in U.S.?


Can you lift 50lbs.?


Is there a reason or condition that may hinder you from performing your job duties?


Have you ever been convicted of a criminal offense?


If yes, please explain the nature of the offense, where the offense occurred, date and sentence imposed:


Do you have a valid Georgia Driver's License?


State/ Driver's License Number


Do you have a Special Operator's license?


If yes, indicate State/ Number


Have you every been convicted of any moving violations or been involved in a vehicular accident in the past 3 years?


Will you be willing to submit to a Fingerprinted Federal Background Check prior to employment at Jericho?


Are you currently abusing drugs or alcohol?


Are you willing to take a drug test prior to employment as well as randomly if hired?


Have you ever been discharged or forced to resign from a position?


If yes, please explain:


Please list your days and hours of availability:


Please indicate your highest level of education including the name of the school, city, state, major/ degree, and if you graduated:


Please list all skills relevant to the position that you are applying for:


Please list all obtained licenses and/ or certifications:


Please summarize other experiences, skills or qualifications that you feel would qualify you for the position which you have applied (e.g. professional organizations, clerical skills, computer abilities etc.):


Name of most recent employer:


Phone Number:


Street Address:


City, State, Zip:


Job Title:


Name/ Title of Supervisor:


Beginning Salary/ Ending Salary:


Dates of Employment (Start/ End):


Describe Responsibilities:


Reason for Leaving:


Name of Reference:


Reference Contact information (Address/ Phone Number):


Name of 2nd Reference:

 


2nd Reference Contact information (Address/ Phone Number)


Resume (Copy & Paste if Available):


I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I understand that the making of false statements will be grounds for rejecting this application outright and termination of employment if hired. (Digital Signature):


Date: MM-DD-YYYY


Questions or feedback


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