APPLICATION FOR EMPLOYMENT
 

We appreciate your interest in our organization. A clear understanding of your background and work history will aid us in placing you in the position that best meets your qualifications and the needs of Dungarvin. We are an Equal Opportunity Employer.
 

If you are interested in a direct care position, prior to completing this application please consider reviewing Dungarvin's realistic job preview.
 

Name:

Address:

City:

State:

Zipcode:

Home Phone Number:        Daytime Phone Number:  

 

POSITION FOR WHICH APPLICATION IS BEING MADE AND HOURS AVAILABLE TO WORK
 

Position(s) applied for:  

Specific source of referral:  

Location preference(s):  

Date available for employment:  

Hours Available (check all that apply):

  Part-time       Full-time       Sleep Nights       Awake Nights       Live In       Weekends
 

PERSONAL INFORMATION
 

Are you at least 18 years of age?        Yes        No

Do you have a valid, current driver's license?        Yes        No

Have you had any traffic violations (excluding parking) within the past three years?        Yes        No

If yes, explain briefly:  

Are you legally eligible to work in the US?        Yes        No     (Proof will be required upon employment)

Have you ever been convicted of a crime that would disqualify you from employment? Please contact the state with which you applying to obtain a list of criminal convictions that would disqualify you from employment with Dungarvin.         Yes        No

If yes, please explain briefly:  

List any special skills you have that you think would be beneficial to Dungarvin and/or the position:
 

EDUCATION
NAME & ADDRESS DID YOU
GRADUATE?		 DATE OF
GRADUATION		 DEGREE OR
AREA OF
STUDY
HIGH SCHOOL   Yes     No Not Applicable Not Applicable
COLLEGE   Yes     No
OTHER   Yes     No Click Here to Pick up the date

Do you have any specific license or certificates pertinent to this position?        Yes        No

Type of license and number:     

Have you ever been employed by Dungarvin or by a program/facility managed by Dungarvin?        Yes        No

If yes, in what state(s), home(s), position(s), and dates?

Have you ever been disciplined or asked to leave a position?        Yes        No

If yes, please explain briefly:  
 

EMPLOYMENT HISTORY

May we contact your present employer?        Yes        No

If no, please explain:  

 
 

List below past and present employers, beginning with the most recent:

Employer 1:  

Dates:      From:   Click Here to Pick up the date     To:   Click Here to Pick up the date        Full-Time     Part-Time

Address:   

City:

State:

Zipcode:

Job Title:      Hourly Rate/Salary:  Start:     Final:  

Supervisor:      Phone:      

Job Duties and Responsibilities:  

Reason for Leaving:  
 
 

Employer 2:  

Dates:      From:   Click Here to Pick up the date     To:   Click Here to Pick up the date        Full-Time     Part-Time

Address:   

City:

State:

Zipcode:

Job Title:      Hourly Rate/Salary:  Start:     Final:  

Supervisor:      Phone:    

Job Duties and Responsibilities:  

Reason for Leaving:  
 
 

Employer 3:  

Dates:      From:   Click Here to Pick up the date     To:   Click Here to Pick up the date        Full-Time     Part-Time

Address:   

City:

State:

Zipcode:

Job Title:      Hourly Rate/Salary:  Start:     Final:  

Supervisor:      Phone:        

Job Duties and Responsibilities:  

Reason for Leaving:  
 

PROFESSIONAL REFERENCES

Please list at least 3 PROFESSIONAL REFERENCES who would be willing to comment on your work abilities. Professional references are people who are familiar with your work. Do not list family, relatives, or friends.
 

Reference 1:  

Address:   

City:

State:

Zipcode:

Phone:    Working Relationship:       How Long Known?  
 
 

Reference 2:  

Address:   

City:

State:

Zipcode:

Phone:      Working Relationship:      How Long Known?  
 
 

Reference 3:  

Address:   

City:

State:

Zipcode:

Phone:      Working Relationship:      How Long Known?  
 
 

Reference 4:  

Address:   

City:

State:

Zipcode:

Phone:      Working Relationship:      How Long Known?  
 
 

Reference 5:  

Address:   

City:

State:

Zipcode:

Phone:      Working Relationship:      How Long Known?  
 

By pressing the submit button on this electronic application, I authorize this organization to contact present and previous employers, references, and to investigate any statements contained in this application. I understand that my driving record may be checked. I further understand that, if offered a position, I will receive the physical requirements for that position and will be asked to verify my ability to perform them. I understand that, upon hire, my hiring and continued employment will be subject to the conditions of employment required by licensing and regulatory agencies and Dungarvin policy.
 

I understand that any misrepresentations or omission of material fact on this application form, or in the course of the application process, may prevent me from being hired, or if hired, is cause for immediate termination of employment.

If employed previously by Dungarvin or a home managed by Dungarvin, my former personnel record(s) may be available to the hiring supervisor. The hiring supervisor may also contact any of my previous Dungarvin supervisors.
 

Today's date:   

To which state are you applying?     
Click this link to review the US Dept. of Labor Employee Polygraph Protection Act