Employment Application Employment Application For Direct Support Professionals & Care Staff Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Applicant Information Full Name *FirstLastAddressCityStateZipPhone NumberEmail Address *Date of BirthPosition Applying ForCFSS Support WorkerHomemakerCompanionICLS Support StaffEmployment Support SpecialistRespite WorkerOtherOther Certifications Phone Other AvailabilityFull TimePart TimeWeekendsNightsFlexibleWork Eligibility Are you legally authorized to work in the U.S.?YesNoDo you have a valid driver’s license?YesNoDo you have reliable transportation?YesNoExperience Do you have experience working with:SeniorsIndividuals with disabilitiesMental healthBehavioral supportPersonal care assistancePlease describe relevant experienceCertifications (if any)CPR / First AidPCA / CFSS TrainingDSP CertificationCNAOtherOtherBackground Information Have you ever been convicted of a crime (excluding minor traffic offenses)?YesNoIf yes, please explain:References Reference 1 Name *PhoneRelationship Applicant Statement Applicant StatementI certify that the information provided is true and complete. I understand that false information may disqualify me from employment.Name *Signature Clear Signature DateSubmit
