1. Full-Time Part-Time
You may be hired for a specific shift, however, requirements of the agency may necessitate that you work other locations, hours, and overtime. Is this acceptable to you? Yes No
2. Hours and days you are able to work
3. How did you hear about Cheyenne Village, Inc.? Walk-in Employee Relative Job Service Advertisement - Source Other - Name of Source (if applicable)
4. Have you previously filed an application at Cheyenne Village, Inc.? Yes - When? No Under another name?
5. Have you been previously employed by Cheyenne Village, Inc.? Yes - When? No Under another name?
6. If hired, can you submit proof that you are at least 21 years of age? Yes No
7. Have you ever been convicted of a felony charge? Yes No If yes, you will be expected to explain at time of interview
8. Have you ever been convicted of a misdemeanor involving abuse, neglect, assault, theft, or fraud? Yes No If yes, you will be expected to explain at time of interview
9. Have you had any traffic tickets or accidents in the last five (5) years? Yes No If yes, please explain:
10. Do you have a current, valid U.S. Driver's License? Yes No
EDUCATION
High School Name Address Check one: GED Diploma
College Name Address Graduate? Yes No Major/Degree Dates of Attendance (format: mm/yyyy to mm/yyyy)
Special Training Name Address Graduate? Yes No Major/Degree Dates of Attendance (format: mm/yyyy to mm/yyyy)
Do you have any computer skills? Yes No if yes, please rate overall proficency: Beginner Intermediate Advanced List applications/programs
Please explain why you want to work with adults who have a developmental disability.
What skills/strengths do you have for this position?
Employment Record (Start with most recent employer and explain ALL "gaps in employment.")
1 Employer Phone Address City/State Position Salary Supervisor Employed from to Reason for leaving: Job Duties May we contact this employer? Yes No
2 Employer Phone Address City/State Position Salary Supervisor Employed from to Reason for leaving: Job Duties May we contact this employer? Yes No
3 Employer Phone Address City/State Position Salary Supervisor Employed from to Reason for leaving: Job Duties May we contact this employer? Yes No
4 Employer Phone Address City/State Position Salary Supervisor Employed from to Reason for leaving: Job Duties May we contact this employer? Yes No
Please explain gaps in employment
1 Name Phone Title In what capacity did you know this person? Company Address City/State
2 Name Phone Title In what capacity did you know this person? Company Address City/State
3 Name Phone Title In what capacity did you know this person? Company Address City/State