Employment Application

Name
First Last
Phone Number*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
E-mail*

Please provide us with an active e-mail account as we may contact you by phone or e-mail to schedule interviews.
Postal Code

Do you have a valid drivers license?*
- Yes
- No
- Suspended
If you are licensed in a different state please make not of that at end of the application.
Driver's License*
Please provide the following: 1. License number 2. Expiration date 3. Class 4: Do you have a clean driving record? If no, please explain.
How many years have you had a drivers license?*

Drivers permit not included.
Have you ever been investigated or currently under investigation with DHHS?*
- Yes
- No
Please explain
If you answered, "yes" to the above question please explain.
Are you able to lift 25lbs?*
- Yes
- No

Are you certified as a DSP?
- Yes
- No
Are you certified as a BHP?
- Yes
- No
Are you certified in CPR/First Aid?
- Yes
- No
Expiration Date
If you are CPR/First Aid certified please provide the expiration date.
Are certified as a CRMA?
- Yes
- No
Expiration date
If you answered, "yes" please provide the expiration date for that certification.
Management Experience
What training/experience (if any) have you had in management and/or supervisory positions?
What is your experience with computers?

Do you have a high school diploma or GED?*
- Diploma
- GED
Please pick one
High School Name and Location*
What is your college experience?
Were you in the US Armed Forces?
- Yes
- No

Most Recent Employer*
Phone Number
Address of the most recent employer

Please provide the full address of your most recent employer.
Job Title
Dates Worked (To and From)*

Please provide the month date and year of your start date and date of your most resent employer.
Immediate Supervisor's Name and Phone Number*
May we contact them?
- Yes
- No
Duties and reason for leaving
Please explain, in detail, your job duties and reason for leaving.
Previous Employer
Address of the previous employer

Please provide the full address of your previous employer.
Dates Worked (To and From)

Please provide the month date and year of your start date and date of your previous employer.
Immediate Supervisor's Name and Phone Number
May we contact them?
- Yes
- No
Duties and reason for leaving
Please explain, in detail, your job duties and reason for leaving.
Previous Employer
Address of the previous employer

Please provide the full address of your previous employer.
Dates Worked (To and From)

Please provide the month date and year of your start date and date of your previous employer.
Immediate Supervisor's Name and Phone Number
May we contact them?
- Yes
- No
Duties and reason for leaving
Please explain, in detail, your job duties and reason for leaving.

Reference #1*
Please provide all of the following: 1. Reference Name 2. Reference Number and Address 3. Work Relationship **List only work related, non-family, verifiable references.
Reference #2*
Please provide all of the following: 1. Reference Name 2. Reference Number and Address 3. Work Relationship **List only work related, non-family, verifiable references.
Reference #3*
Please provide all of the following: 1. Reference Name 2. Reference Number and Address 3. Work Relationship **List only work related, non-family, verifiable references.

Authorization to Release Data- If you agree to the terms please type your full name. I certify the above information is true, and I understand the signing of this authorization form effectively serves as a release of information and gives permission to The Progress Center, Inc. to obtain a report of any civil or criminal history; of motor vehicle records; and of any DHHS protective/guardian services information which may be on file in any county, state or federal office. In filling out this authorization form, I agree to cooperate in the investigation and that statements on this form and other information which has been disclosed to The Progress Center, Inc. will be correct. Any false statements, misrepresentations or reports/information obtained through this release which The Progress Center, Inc. may find objectionable will be a basis for refusing or releasing me from employment with The Progress Center, Inc.*
I understand the following:*
- Yes
- No
The Progress Center must receive references within 30 days of date of hire. All successful applicants must pass all background checks, including a Child Protective check (for applicants working with children). All successful applicants must have a high school diploma or GED or obtain one within 60 days of hire.
I received the Notice of Nondiscrimination*
- Yes
- No
NOTICE OF NONDISCRIMINATION: The Progress Center, Inc. will recruit and employ qualified personnel and will provide equal opportunities during employment without regard to race, color, religion, sex, sexual orientation, national origin, age, disability or status as a Vietnam era veteran. Anyone having inquiries concerning The Progress Center’s compliance with this nondiscrimination resolution is encouraged to contact the Affirmative Action/Equal Opportunity Office. The Progress Center is an Equal Opportunity Organization.
Applicant's Signature*

By providing your full name you certify that the information contained in this application is true and that you are applying for a paid position with The Progress Center. This organization is a drug-free equal opportunity employer.

Voluntary Self Identification Form
The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to invite applicants to self-identify gender and race and complete an EEO-1 report each year. Completion of this data is voluntary and will not affect your opportunity for employment, or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department.
First Last
Position Applying For
Gender
Race/Ethnicity
(Please check one of the descriptions below corresponding to the ethnic group with which you identify.)
- Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
- White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
- Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa.
- Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.
- Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
- American Indian or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
- Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Employment Application

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