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ACGH Director
Alleghany ADAP Services – PT & FT
Direct Support Professional – Part Time & Full Time
Employment Application
Please submit the below online application or print the
pdf file
at the bottom of this page and return to our office.
Alleghany County Group Homes, Inc.
(An Equal Opportunity Employer)
Employment Application
APPLICANT NOTE: This application form is intended for use in assisting us evaluating your qualifications for employment. This is not an employment contract. Please print all answers and answer all question truthfully and completely. Any person found to have intentionally misrepresented or omitted any material fact herein, will automatically be disqualified from further consideration or employment. All qualified applicants will receive consideration for employment without discrimination based on age, sex, national origin or any other protected classification. A prior felony conviction will not automatically disqualify you from employment.
Affirmative action hiring may be requested by qualified applicants. Additional testing of skills directly related to essential job function and testing for presence of drugs or alcohol in your body may be required prior to employment.
Applicant Information
*
Indicates required field
Position Applied for:
*
Date Available:
*
Desired Salary
*
Are you interested in:
*
Part Time
Full Time
Any Available
Availability
*
Weekdays
Weekends
Evenings
Nights
Overtime
Shift
Days Available
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Years of Direct Support Experiance
*
Full Name
First
*
M.I.
*
Last
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Social Security No.
*
Have you used any names or Social Security Numbers other than those listed?
*
Yes
No
If yes please List:
*
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the U.S.?
*
Yes
No
Have you ever worked for this company?
*
Yes
No
If yes, when and what position?
*
Do you currently have a valid license to operate a motor vehicle in this state?
*
Yes
No
Driver's License #
*
Have you received any notice that such license may or will be suspended or revoked at any time in the future?
*
Yes
No
Have you ever been convicted of a felony and/or served time in the past (7) years?
*
Yes
No
If yes, please explain
*
Incident Date
*
City/State
*
Charge
*
Please write a couple of paragraphs about why you would like work in the field of developmental disabilities. Include a summary of your work experience in this field or talk about people you have known who were developmentally disabled. Also, write something about yourself that is unique; something in which you are very interested. a hobby or how you like to spend your leisure time.
Paragraphs:
*
Education
High School
*
City/State
*
Did you graduate?
*
Yes
No
Year Graduated
*
Diploma
*
College
*
City/State
*
Did you graduate?
*
From
*
To
*
Degree
*
Other
*
City/State
*
Did you graduate?
*
From
*
To
*
Degree
*
Previous Employment
List your employers in order with the last or present employer first.
Company
*
City & State
*
Job Title
*
Responsibilities
*
Phone Number
*
Supervisor
*
Starting Salary
*
Ending Salary
*
Start Date
*
End Date (place N/A if still employed)
*
Reason for leaving
*
May we contact your previous supervisor for reference?
*
Yes
No
Company
*
City & State
*
Job Title
*
Responsibilities
*
Phone Number
*
Supervisor
*
Starting Salary
*
Start Date
*
Ending Salary
*
End Date
*
Reason for leaving
*
May we contact your previous supervisor for a reference?
*
Yes
No
Company
*
City & State
*
Job Title
*
Responsibilities
*
Phone Number
*
Supervisor
*
Starting Salary
*
Ending Salary
*
Start Date
*
End Date
*
Reason for leaving
*
May we contact your previous supervisor for a reference?
*
Yes
No
References
Please list three
professional
references.
Full Name
*
Company
*
City & State
*
Relationship
*
Phone Number
*
Years Known
*
Full Name
*
Company
*
City & State
*
Relationship
*
Phone Number
*
Years Known
*
Full Name
*
Company
*
City & State
*
Relationship
*
Phone Number
*
Years Known
*
Resume Upload
Upload File
*
Max file size: 20MB
Disclaimer and Certification of Authenticity
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
"I certify that I have read and understand the applicant note on the front page of this form and that all answers given by me herein are true and correct to the of my knowledge and beliefs I, hereby authorize the company, its agents and servants, and any reporting agency, to verify any information set forth herein including, but not limited to, my criminal history and motor vehicle driving record. I further authorize all. persons, schools, former employees and law enforcement agencies to release such information as the company may request concerning my past, and do hereby release such person, school, former employer and law enforcement agency from any liability or damages which may
result therefrom, I understand that the use of illegal drugs is prohibited during my employment and do hereby submit to drug testing by or at the direction of company to detect the presence or absence of drugs I my body, both prior to and during my employment therewith."
Certification of Authenticity
*
Yes
No
Name
*
First
Last
Submit
Employment Application
File Size:
66 kb
File Type:
pdf
Download File
