Employment Application Thank you for your interest in Serenity Residential Cares (SRC). Answer each question fully and accurately. The filling of this application does not guarantee employment. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information. Mission: Serenity Residential Cares mission is to serve people with intellectual disabilities and cognitive disorders by providing them with a healthy and safe environment. We strive to empower members who have behavioral disabilities to achieve their day-to-day goals and to help them gain access to available community resources, in a safe and enjoyable manner. Our Core Values: Hope Safety Empowerment EEO Statement: Serenity Residential Cares is an equal opportunity employer and does not discriminate on the basis of age, race, color, religion, national origin, sex, ancestry, genetic information, retaliation, gender identity, sexual orientation, disability, pregnancy, military service, marital status, whistleblower, worker’s compensation, or physical or mental employment discrimination. For any questions, please email hr[at]serenity-cares.com or 207-650-7346 Personal InformationJob Applied for*Select PositionDirect Support Professional (DSP) IDirect Support Professional (DSP) IIDirect Support Professional (DSP) IIIHouse Manager IHouse Manager IIHouse Manager IIIToday's Date* MM slash DD slash YYYY Expected Start Date* MM slash DD slash YYYY Employment type*Select an ItemFull-TimePart-TImeTemporaryFull Name* Phone Number*Email Address* Street Address Address Line 2 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 Are you 18 years of age or older?*Select an itemYesNoIf hired, can you furnish proof you are eligible to work for SRC in United States?*Select an itemYesNoHave you ever applied here before? If yes, explain when*Select an optionYesNoExplain when did you appliedIf employed, do you expect to be engaged in any additional business? If yes, explain*Select an itemYesNoIf yes explainDo you have a valid driver’s license?*Select an optionYesNoList any professional, trade, business, or civic activities & offices held Please list all licenses and certifications you now hold* DSP CPR and first aid CPI CRMA Insulin Epi-pen None Other licenses you hold?Shift PreferencePlease check which days and shift you are available to workSunday Select All A Shift (8am-4pm) B Shift (4pm-12am) C Shift (12am-8am) Monday Select All A Shift (8am-4pm) B Shift (4pm-12am) C Shift (12am-8am) Tuesday Select All A Shift (8am-4pm) B Shift (4pm-12am) C Shift (12am-8am) Wednesday Select All A Shift (8am-4pm) B Shift (4pm-12am) C Shift (12am-8am) Thursday Select All A Shift (8am-4pm) B Shift (4pm-12am) C Shift (12am-8am) Friday Select All A Shift (8am-4pm) B Shift (4pm-12am) C Shift (12am-8am) Saturday Select All A Shift (8am-4pm) B Shift (4pm-12am) C Shift (12am-8am) Past EmploymentNote:A job offer may be contingent upon acceptable references from current and former employers.Employer IEmployer Name Address Street Address Address Line 2 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 Job Duties Reason for Leaving Supervisor Phone NumberStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Employer IIEmployer Name Address Street Address Address Line 2 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 Job Duties Reason for Leaving Supervisor Phone NumberStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY EducationSchool Name Mail Address Year CompletedDegree or Diploma Have you ever been fired from a job or asked to resign? If yes, explain*Select an itemYesNoIf yes, explainAttach two letters of recommendation or three references to the applicationLetter of recommendation Drop files here or Select files Accepted file types: docx, doc, pdf, Max. file size: 5 MB, Max. files: 2. References Drop files here or Select files Accepted file types: docx, doc, pdf, Max. file size: 5 MB, Max. files: 3. Please read each statement carefully before signingI certify that all information provided in this employment application is true and complete. I understand any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinion that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that this application, verbal statement by management, or subsequent employment does not create an express or implied contract of employment nor guarantee employment for any definite period of time. Only the president of the organization has the authority to enter into an agreement of employment for any specified period and such agreement must be in writing. Signed by the president and the employee. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without reason and with or without notice. I have read, understand, and by my signature consent to these statements. Electronic Signature* I agree to this statement.I certify that all information provided in this employment application is true and complete. I understand any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinion that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that this application, verbal statement by management, or subsequent employment does not create an express or implied contract of employment nor guarantee employment for any definite period of time. Only the president of the organization has the authority to enter into an agreement of employment for any specified period and such agreement must be in writing. Signed by the president and the employee. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time, with or without reason and with or without notice. I have read, understand, and by my signature consent to these statements.Today's Date* MM slash DD slash YYYY Volunteer Self-Identification EEO SurveyEEO Statement: Serenity Residential Cares is an equal opportunity employer and does not discriminate on the basis of age, race, color, religion, national origin, sex, ancestry, genetic information, retaliation, gender identity, sexual orientation, disability, pregnancy, military service, marital status, whistleblower, worker’s compensation, or physical or mental employment discrimination.Let's verify that you are humanEmailThis field is for validation purposes and should be left unchanged.