Residential Resources: Online Application

Contact Information:
First Name		Last Name
Address		City
State		Zip
Telephone		Email

General Applicant Questions:
Are you a US Citizen or legally eligible for employment in the US?	Yes No
Do you posess a current driver's license?	Yes No
Do you have an automobile available to transport consumers?	Yes No
Have you ever been convicted of a crime (includes misdemeanors and felonies) which has not been annulled by a court?	Yes No
Are you or have you ever been excluded from participating in Medicaid and/or Medicare?	Yes No
Has an allegation of abuse and/or neglect ever been founded against you?	Yes No
If you answered yes to any of the last three questions, please describe in complete detail below. Please note that an affirmative answer does not necessarily mean immediate disqualification for the position available.

Position Information:
Position Desired		Full Time Part Time Relief
How did you learn about us? A Friend A Relative Walk In Job Posting Advertisement	Other, or which advertisement:
Do you currently have relatives working at this organization?		Yes No
If so, please identify:

Education:
High School
High School Major
High School Degree
College
College Major
College Degree
Other School
Other Major
Other Degree

Employment History:
Employer		Supervisor
Address		Phone
Employment Dates		Reason for Leaving
May we contact?		Yes No
Employer		Supervisor
Address		Phone
Employment Dates		Reason for Leaving
May we contact?		Yes No
Employer		Supervisor
Address		Phone
Employment Dates		Reason for Leaving
May we contact?		Yes No

References:
Please provide contact details of three personal or professional reference not related to you.
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number

Please Read:

By completing this application and clicking "Submit Application" below, I authorize WKS, Inc. and any agent acting on its behalf, to conduct an inquiry of my record of any or all of my former and present employers, references, educational institutions, and of any felony convictions or history of child/client abuse. All responses are correct to my knowledge. I understand that misstating or omission of any relevant information is basis for termination at any time. I further understand that WKS, Inc. is an “employment at will” employer and therefore my employment and compensation can be terminated at any time with or without cause.

YOUR ADDRESS: 38.103.63.18
DATE/TIME: 7/4/2008 11:14:20 AM

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