Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastEnter Your Street Address *City, State, Zip Code: *Date of Birth: *Ex: 5/1/1985Telephone # *Ex: 484-111-0000Email *Do you have a Valid and Current Driver's License? *YesNoDrivers License # *Ex: 123456789Do you have a working car?YesNoAre You a Veteran?YesNoHave you ever been convicted of a crime? *YesNoIf “Yes” to the above question, please state type of conviction and year. If “No” then skip to the next question.If hired are you willing to submit to a background check that includes your SSN? *YesNoHave you lived in the state of Pennsylvania for less than 2years? (if yes then a FBI Background check will be required) *YesNoWhat Position you are applying for:SELECT FROM DROP-DOWNCLINICAL DIVISION COORDINATORDIRECT SUPPORT ASSICIATE DIRECT SUPPORT COORDINATORRESIDENTIAL SERVICE DIRECTORCERTIFIED INVESTIGATORQUALITY MANAGERDIRECTOR OF COMPLIANCEGENERAL SERVICES COORDINATORConsider me for future employmentI am applying for: *FulltimePart-TimeSeasonal/TemporaryOn-CallAvailable date to start:Days available to workSundayMondayTuesdayWednesdayThursdayFridaySaturdayWhat shift are you interested in? (Note shift preference can not be guaranteed)8AM-4PM4PM-12AM12AM-8AMDesired pay:Most Recent Employer 1. Employer's Name:Employer 1 Address, City, Zip, State:Job Title 1:Date Employment 1. Enter Start - End Date:Ex: May 25th 2010-PresentStarting & Ending Pay Rate for Job 1: Ex: $8/hr - $12/hr Or $30K a yearMost Recent Employer 2. Employer's Name:Employer 2 Address, City, Zip, State:Job Title 2:Date Employment 2. Enter Start - End Date:Starting & Ending Pay Rate for Job 2: Highest level of Education *No Education/NoneHigh School Diploma/ G.E.DAssociates DegreeBachelors DegreeMaster Degree(M.B.A)PHD/Doctorate DegreeWhat year did you graduate:Name of School or College:Street Address of School or College, City, State, Zip Code:Do you have prior work experience in Human Services or as a DSP/DSA *YesNoDo you have a special license or certification:YesNoAre you certified on CPR?YesNoIf you have, List Name of Certification & Year of Certification:Name of Institution granting the Certification:Street Address of Institution or College, City, State, Zip:References: List Reference 1. Full Name: List Address, City, State, Zip for Reference 1: List Email for Reference 1: List Telephone Number for Reference 1: Reference 2. Full Name:List Address, City, State, Zip for Reference 2: List Email for Reference 2: List Telephone Number for Reference 2: Race:White or CaucasianBlack, African, or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderOtherType Today's Date: *Ex: 1/20/2017 Or January 20th 2017Type your Initials:THIS COMPANY IS AN AT-WILL EMPLOYER WHERE ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY. IF HIRED, I AGREE TO CONFORM TO THE LAWFUL RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL UNLESS SUCH AGREEMENT IS SIGNED BY THE PRESIDENT OF THE COMPANY. *ConfirmedPlease Sign Here & Date *PhoneSubmit