Employment Application — Always Love Group Home

APPLICATION FOR EMPLOYMENT

Always Love Group Home is an Equal Opportunity Employer. We do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by law. All information provided will be kept confidential and used only for employment purposes.

Personal Information

Full Legal Name (Last, First, Middle)

Date of Application

Street Address

Apt / Unit #

City

State

ZIP Code

Phone (Primary)

Phone (Alternate)

Email Address

Position & Availability

Position(s) Applied For

Date Available to Start

Employment Type:

Full-Time

Part-Time

PRN / As Needed

Either

Shift Preference:

Day

Evening

Overnight

Weekends

Flexible

Valid NC Driver's License:

Yes

Reliable Transportation:

Yes

Education

School Name & Location	Degree / Diploma / Certificate	Field of Study	Years Attended	Graduated?

Certifications & Licenses

List any relevant certifications or licenses (CPR, First Aid, CNA, QP, CADC, etc.)

Employment History (Most Recent First)

Employer Name & Address	Job Title	Dates (From–To)	Pay Rate	Reason for Leaving

May we contact your current or most recent employer?

Yes

Relevant Skills & Experience

Describe any experience working with individuals with intellectual/developmental disabilities, mental health, or behavioral health needs

List any additional skills relevant to this position

Professional References (Not Family Members)

Full Name	Relationship / Title	Phone Number	Years Known

How Did You Hear About Us?

Google Search

Online Advertisement

Referred by a friend or family member

Referred by a healthcare provider

Referred by a case manager or social worker

Community event or outreach

Other — please specify

Name of person who referred you (if applicable)

Background Disclosure

Have you ever been convicted of a felony or misdemeanor?

Yes

If yes, please explain (a conviction does not automatically disqualify you)

Applicant Certification & Signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information may result in disqualification from consideration or termination of employment. I authorize Always Love Group Home to verify the information provided and to contact references and former employers. I understand that employment is contingent upon successful completion of a background check and drug screening.

Applicant Signature

Date

Printed Name