Hearth Residential Homes/ALP Application

Please fill the form below as thoroughly as possible.

Full Name:	Last First M.I.
Address:	Street Address Apt/Unit #
	City State Zip
Phone:	E-mail Address:
Position Applied For:	Social Security Number: Desired Salary: $

How did you Learn about us?	When would you be available to work?
Are you currently Employed? Yes No	If yes, may we contact your employer? Yes No
Can you travel if your job requires it? Yes No	Are you currently on a layoff and subject to recall? Yes No
Are you physically or otherwise unable to perform the duties of the job for which you are applying? Yes No
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?
Have you ever been convicted of a felony? Yes No	If yes, Explain:

Education
High School:	Address:
From: To:	Did you graduate? YesNo	Degree:

College:	Address:
From: To:	Did you graduate? YesNo	Degree:

Other:	Address:
From: To:	Did you graduate? YesNo	Degree:

Languages
Indicate any foreign languages you can speak, read and/or write
Language:
	Fluent	Good	Fair
Speak
Read
Write

List professional, trade, business or civic activities and office held. (You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status.)
Please list three professional references.

References

Full Name		Relationship:
Company		Phone
Address		E-mail Address

Full Name		Relationship:
Company		Phone
Address		E-mail Address

Full Name		Relationship:
Company		Phone
Address		E-mail Address

Previous Employment

Company:		Phone:
Address:		Supervisor:
Job Title:
Starting Salary:		Ending Salary:
From:		To:
Responsibilities:
Reason for Leaving:

Company:		Phone:
Address:		Supervisor:
Job Title:
Starting Salary:		Ending Salary:
From:		To:
Responsibilities:
Reason for Leaving:

Company:		Phone:
Address:		Supervisor:
Job Title:
Starting Salary:		Ending Salary:
From:		To:
Responsibilities:
Reason for Leaving:

Military Service
Branch:	From:	To:
Rank at Discharge:	Type of Discharge:
If other than honorable, explain:

Physical Job Requirements

Job Title	Job Coach/Program Assistant
Date
Supervisor Name

Section I (to be completed by supervisor)

1. Percent of time spent for each activity:

Sitting	10	%
Standing	20	%
Moving about	70	%

2. Does the job require:

Talking	X	Yes	No
Hearing	X	Yes	No
Seeing	X	Yes	No
Manual dexterity	X	Yes	No
Finger dexterity	X	Yes	No
Driving a motor vehicle	X	Yes	No
Other		Yes	No

3. Job requires:

	Never	Occasionally	Frequently
Bend/stoop			X
Climb stairs			X
Reach above shoulder level			X
Crouch			X
Kneel			X
Balance			X
Push/pull			X
Restraining		X

4. Job requires carrying:

	Never	Occasionally	Frequently
Up to 10 lbs.			X
10 to 50 lbs.			X
50 or more lbs.		X

5. Job requires lifting:

	Never	Occasionally	Frequently
Up to 10 lbs.			X
10 to 50 lbs.			X
50 or more lbs.		X

Additional comments:

Section II to be completed by conditional hire

Is there anything that would hinder you from performing the physical requirements described in Section 1 of this form?

Yes No

If yes, please identify which aspects of the job would pose a problem for you.

I certify that my answers are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledge in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the employer.

I Agree