APPLICATION FOR EMPLOYMENT SERENITY RESIDENTIAL SERVICES 2406 University Blvd W. Jacksonville, FL 32217-2002 (904) 379-8914 FAX: (904) 800-1465 E-mail: srsinc2013@gmail.com Thank you for your interest in employment with Serenity Residential Services! All applicants for all positions are considered without regard to race, color, religion, creed, gender, age, disability, national origin, ethic, martial or veteran status, or any other legally protected status. PLEASE PRINT CLEARLY DATE: POSITION APPLIED FOR: Direct Care Assistant - Day Shift Direct Care Assistant Overnight Other DATE AVAILABLE: MINIMUM ACCEPTED SALARY: DESIRED POSITION: Full-Time Part-Time Any I am available any day, any time List days/hours available to work, write N/A for days not available Sunday Monday Tuesday Wednesday Thursday Friday Saturday How many hours can you work weekly? If applied for day shift, can you work nights? Yes No PERSONAL INFORMATION FIRST NAME MIDDLE NAME LAST NAME MAIDEN NAME MAILING ADDRESS Street Address Apartment/Unit # City State Zip Code County PHONE ALTERNATE PHONE E-MAIL: Are you a citizen of the United States? Yes No If no, are you authorized to work in the U.S.? Yes No Have you ever worked for this company? Yes No If yes, when? Have you ever been convicted of a felony? Yes No If yes, explain: Do you have a valid driver s license? Yes No If yes, what state: Do you have any violations on your driving record history? Yes No If yes, explain:
EDUCATION (Transcript is required) High School: State: Year Graduated: College: State: Years Completed: Degree Received: Other: Degree Received: Certification(s) Received: List any specialized training and skills (i.e. CPR/First Aid, HIV/Infection Control, Zero Tolerance, Core Competencies, etc.): EMPLOYMENT HISTORY Have you ever worked with people with developmental disabilities? Yes No If yes, what company: Have you ever been accused of abuse or asked to resign by a previous employer? Yes No If yes, explain: _ PLEASE LIST WORK EXPERIENCE (List two most recent jobs. You can submit a resumé with a detailed list of work history.) Company: Phone: Supervisor: Job Title: Starting Salary: $ Ending Salary: $ Responsibilities: From: To: Reason for Leaving: May we contact the supervisor for a reference? Yes No Company: Phone: Supervisor: Job Title: Starting Salary: $ Ending Salary: $ Responsibilities: From: To: Reason for Leaving: May we contact the supervisor for a reference? Yes No Page 2 of 5
REFERENCES Please list three professional references. REFERENCE 1 Full Name: Relationship: REFERENCE 2 Full Name: Relationship: REFERENCE 3 Full Name: Relationship: I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview will be sufficient cause for cancellation of application and/or separation from the employer s service if I have been employed. I authorize SRS to verify all the information included on this application (and accompanying resume, certificates, transcripts, if any) and to verify and investigate all references. I further authorize SRS to investigate my Motor Vehicle records and any other job related data through any agencies it so chooses. I hereby release from liability the Agency and its representatives for seeking such information and all other persons, businesses, or corporations for furnishing such information. I understand this application is current for only 30 days. After this time, if I have not heard from SRS and still wish to be considered for employment, it will be necessary to fill out a new application. Signature Date Page 3 of 5
APPLICATION QUESTIONNAIRE Name: Date: Please take a moment and answer the below questions as thoroughly and accurately as possible. There are no right or wrong answers. These questions will assist us in reviewing your application and help to determine what position in which you would be best qualified. Serenity Residential Service s Mission To generate and maintain a nurturing and reliable organization, which provides individualized highquality care that meets the personal strength and needs of the individuals we serve. 1. If hired, how would you contribute to our company s mission? 2. Why would you like to be part of our company? 3. Give an instance in which you conformed to a policy you did not agree with? 4. A co-worker is not completing his/her task(s), how do you respond? 5. Give an example of a time you did more than what was required in your job. 6. If a person you are providing services to hits you in the face, how would you respond? 7. What are your interests and hobbies outside of work? Page 4 of 5
SERENITY RESIDENTIAL SERVICES 2406 University Blvd W. Jacksonville, FL 32217-2002 (904) 379-8914 FAX: (904) 800-1465 www.srscares.org AUTHORIZATION FOR RELEASE OF INFORMATION PERTAINING TO CRIMINAL AND PAST RECORDS To Whom It May Concern, I am applying for the position with Serenity Residential Services, Inc. I hereby authorize Serenity Residential Services, Inc. to obtain: 1. Business/Personal References 2. Education Verification (e.g. transcripts) 3. Copies of my Level II Background Check 4. Copies of my Local Law Screenings 5. Copies of my driving record (if applicable) During the past 5 years, I have resided in the following places. (Please include addresses, including county, and the dates you resided at each location.) 1. 2. 3. 4. 5. FIRST NAME M.I. LAST NAME MAIDEN NAME MAILING ADDRESS Street Address City State Zip Code PHONE HAIR COLOR EYE COLOR DATE OF BIRTH (mm/dd/yyyy) SOCIAL SECURITY NUMBER DRIVER S LICENSE NUMBER STATE OF BIRTH HEIGHT WEIGHT ETHNICITY Signature Date Page 5 of 5