Date of Birth (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:
City, State, Zip:
Name/ Title of Supervisor:
Beginning Salary/ Ending Salary:
Dates of Employment (Start/ End):
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):
Questions or feedback
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