Application Form Personal Information:What position are you applying for?GH- Direct Care Worker-Male-SAT-SUN 8am-8pmGH-Direct Care Worker- Female-M-F 3pm-11pmGH- Direct Care Worker-Male-SAT-SUN 8am-8pmGH- Direct Care Worker-Female-SAT-SUN 8am-8pmDTA- M-F 8am-4pmDTT Part Time M-F 12pm-6pmOn Call Direct Care WorkerOver Night Direct Care WorkerDirect Care Worker 3pm-11pmFirst Name(Required) Last Name(Required) Email Address(Required) Phone(Required)Address (Please include your apartment number)(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number(Required)Please Check All That Apply Have you ever worked with us before? Do you have a Valid Level 1 fingerprint card? Are you at least 18 years of age? Do you have a valid Drivers License? Available Start Date(Required) MM slash DD slash YYYY Education and Training:Do you have a High School Diploma or College Degree?(Required) How many years of school did you complete?Legal HistoryPlease Check All That Apply(Required) I have never been convicted of a felony. I'm legally authorized to work in The United States I have no pending criminal charges. I'm able to lift 50-100 lbs. I have never been investigated by the Department of Child Safety I have never been investigated by Adult Protective Services. Select AllExplain Your Answers if NecessaryEmployment Experience: Current or Most Recent EmploymentCompany Name Address Street Address Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Supervisor Name Phone NumberPay Rate Job Title and Duties Reason for Leaving If Currently Still Employed, May We Contact As A Reference? Yes No Please Provide Four References. References CANNOT Be Family.Reference One:First and Last Name(Required) Phone(Required)Relationship(Required) Years Known(Required) Reference Two:First and Last Name(Required) First and Last Name(Required)Relationship(Required) Years Known(Required) Reference Three:First and Last Name(Required) Phone(Required)Relationship(Required) Years Known(Required) Reference Four:First and Last Name(Required) Phone(Required)Relationship(Required) Years Known(Required) How Did You Hear About Us? Social Media Family/friend Google Search Third Party Website University School Job Fair What Website? Who Referred You? Resumes Are Not a Substitution. In Addition, You May Submit Your Resume. Drop files here or Select files Max. file size: 256 MB. 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DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall 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