Employment Application

Dominion Residence of Maryland, Inc. is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Dominion Residence of Maryland, Inc., provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Name(Required)

Date(Required)

Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Phone(Required)

Email(Required)

Position applying for:(Required)

How did you hear about this position?(Required)

What days are you available for work?(Required)

What hours or shift are you available to work?(Required)

What date are you available to start?(Required)

PERSONAL INFORMATION

Have you ever applied to or worked for Dominion Residence of Maryland, Inc. before?

Yes

Do you have any friends, relatives, or acquaintances working for Dominion Residence of Maryland, Inc.

Yes

If yes, when?

If yes, state name & relationship:

Are you 18 years of age or older?

Yes

Are you legally eligible to work in the United States?

Yes

Do you have any condition which would require a job accommodation?

Yes

If yes, please describe accommodation required below.

EDUCATION/TRAINING/CERTIFICATIONS

High School

Name

Location (City, State)

Degree Earned

College/University

Name

Location (City, State)

Degree Earned

Vocational School/Specialized Training

Name

Location (City, State)

Degree Earned

Certification/Training

Do you have any prior job related certification/training?

Yes

If yes, share details for below:

CPR

Yes

First Aid

Yes

Medication Administration

Yes

Abuse and Neglect

Yes

Community Integration

Yes

Bloodborne Pathogens

Yes

BPS Training

Yes

Seizure Training

Yes

Diabetes Training

Yes

EMPLOYMENT HISTORY

Employer Name:

Supervisor Name:

Job Title:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

May we contact?

Employer Name:

Supervisor Name:

Job Title:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

May we contact?

Employer Name:

Supervisor Name:

Job Title:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

May we contact?

REFERENCES

List below three persons who have knowledge of your work performance within the last four years. Please include professional references only.

Reference Name

Title & Phone Number

Company

Reference Name 2

Title & Phone Number 2

Company 2

Reference Name 3

Title & Phone Number 3

Company 3

APPLICATION QUESTIONNAIRE

Please answer the questions below as thoroughly and accurately as possible. There are no right or wrong answers. These questions will assist Dominion Residence of Maryland, Inc. in reviewing your application and help to determine which position in which you would be best qualified.

1. Which supervisor have you found easiest to work with and which have been the most difficult?

2. What did you like the most and least about your previous job?

3. Describe a work-related problem you had to face recently. What did you do to deal with it?

4. Give an example of a time you found it necessary to make an exception to the rule in order to get something done.

5. Describe a time when you had to gain the cooperation of a group over which you had little or no authority. What did you do?

6. Have you ever had trouble learning a new method or procedure? How did you deal with the situation? What was the outcome?

REQUIRED INFORMATION

Driver's License(Required)

Max. file size: 5 MB.

Social Security Number(Required)

CPR/First Aid Certification(Required)

Max. file size: 5 MB.

Bloodborne Pathogens Certification(Required)

Max. file size: 5 MB.

CONDITIONAL UPLOADS (only if applicable)

Work Authorization Document

Max. file size: 5 MB.

Green Card

Max. file size: 5 MB.

ADDITIONAL UPLOAD

PPD Test/Physical Exam Documentation

Max. file size: 5 MB.

SIGNATURE DISCLAIMER

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds to not be hired, or for termination should I be hired.

I authorize any person, organization or company listed on this application to furnish Dominion Residence of Maryland, Inc. any and all information concerning my previous employment, education and qualifications for employment.

I also acknowledge that any offer or acceptance of employment may be withdrawn, at any time, with or without cause, and with or without prior notice at the option of Dominion Residence of Maryland, Inc. or myself.

Applicant Name(Required)

Date:

BACKGROUND CHECK FEE

Price:

Credit Card

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