Employment Application Form

Do you have any criminal convictions, findings of guilt, pleas of guilty, and/or pleas of nolo contendere (no contest) exept minor traffic violations?

Yes

Employment History

List the last 5 years of employment with the most recent first. If you were previously an attendant employed by an individual receiving Consumer Directed Services, list them as the Company.

Current/Previous Employer #1

Company Name

Supervisor Name

Date Employed

Position Title

Address

Phone

Duties

Reason for leaving?

May the Participant contact your employer?

Yes

Previous Employer #2

Company Name

Supervisor Name

Date Employed

Position Title

Address

Phone

Duties

Reason for leaving?

May the Participant contact your employer?

Yes

Previous Employer #3

Company Name

Supervisor Name

Date Employed

Position Title

Address

Phone

Duties

Reason for leaving?

May the Participant contact your employer?

Yes

References

List three credible references not related to you.

Reference 1

Name

Relationship

Phone

Address

Reference 2

Name

Relationship

Phone

Address

Reference 3

Name

Relationship

Phone

Address

I certify the answers herein are true and accurate to the best of my knowledge and I hereby authorize performance of a pre-employment criminal record check. I hereby give consent to performance of a closed records check pursuant to the Section 610.120 RSMo. I understand false or misleading information given on this application may result in refusal to hire or if employed, may result in discharge after its discovery.I further understand that all qualified applicants will be considered without regard to race, gender, religion, veteran status, disability, age, sexual orientation, national origin, or any other classification protected by law.