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)


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):


Questions or feedback

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