Job Application – Home For Butterflies

Name:

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address:

Date you can start:

Home Telephone Number:

Cellular Telephone Number:

Who referred you to this position?

Do you have a High School Diploma or GED?

Yes
No

Position applying for:

Home Care Provider
Day Staff
Respite

Hours you can work:

Full Time
Part Time

Are you authorized to work in the United States?

Yes
No

Are you 18 years old or older?

Yes
No

How many people are currently living in your household?

Are there any children under the age of 18 currently living in your household?

Yes
No

Is your home accessible to wheelchairs?

Yes
No

Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment)

Yes
No

If yes, please explain:

Can you perform these essential functions of the job with or without reasonable accommodation?

Yes
No

Training Background: Please select the relevant training from the dropdown list below

QUALIFICATION - Please list all relevant education or training, such as schools attended, degrees earned, vocational or technical programs completed that you feel would help you perform well in the position you are applying for:

SPECIAL SKILLS - Please write about your experience based on the position you’re applying at Home For Butterflies:

WORK HISTORY Start with your present or most recent employment and work back. (INCLUDE PAID AND UNPAID POSITIONS). If you do not have more than one employment history, you may leave this section blank:

Start Date (Month/Year):

Company Name:

End Date (Month/Year):

Supervisor Name:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number:

Duties:

Reason for leaving:

Job Title #2

Start Date (Month/Year):

Company Name:

End Date (Month/Year):

Supervisor Name:

Phone Number:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Duties:

Reason for leaving:

Job Title #3

Start Date (Month/Year):

Company Name:

End Date (Month/Year):

Supervisor Name:

Phone Number:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Duties:

Reason for leaving:

Upload your resume/cover letter:

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

IMPORTANT: PLEASE REVIEW AND AGREE BEFORE SIGNING

I agree to comply with the Agency's rules and regulations if hired.
I understand that my employment may be terminated with or without cause and without notice, at any time, by either the Agency or me.
I authorize the release of background, education, and employment information to the Agency and hold all parties harmless from liability.
If hired, I allow the Agency to provide employment information to prospective employers and certify the accuracy of the information provided in my application.

Applicant Signature:

Todays Date: