Careers Form

* Required Information

Employment Application

Serenity Day Habilitation does not discriminate against any person based on race, national origin, religion, age, or disability in admission, treatment, or participation in its programs, services, and activities or in employment.

Full Name *

Current Address *

City *

State *

Zip *

Phone Number *

Date of Birth *

Social Security Number *

Email *

Are you 18 years of age or older? *

Yes

Are you a military Veteran? *

Yes

Are you legally able to work in the United States? *

Yes

Driver’s License *

Have you worked for Serenity before? *

Yes

When

Position *

EMPLOYMENT DESIRED

Job Title

Date You Can Start

Wage Desired

Are you available for work?

Full-Time

Part-Time

EDUCATION

High School/GED

Name of School

Address

Major

Degree

Technical/Vocational

Name of School

Address

Major

Degree

College/University

Name of School

Address

Major

Degree

Area of Concentration and/or degree(s), Certificates, Licenses, Endorsements

Other Training or Skills (Office Machines Operated, Special Courses, Computer Skills, Used of Word, Excel etc.)

QUALIFICATIONS

The use of illegal drugs is absolutely prohibited under Serenity policy. Serenity does require employees to submit to drug testing as a condition of continued employment. If asked, will you submit to drug testing?

Yes

Have you received three or more traffic violations in the last 3 years?

Yes

Has your driver’s license been suspended or revoked in the last 3 years?

Yes

Have you ever been convicted of or pled guilty to a crime?

Yes

Have you ever been convicted of or pled guilty to a crime involving the abuse, neglect or exploitation of a child or adult?

Yes

Have you ever been adjudged to be civilly or criminally liable for abuse of a developmentally disabled person receiving services from the department or placed in a community residence?

Yes

Able to speak a language other than English?

Yes

Language spoken

Do you possess a valid driver’s license?

Yes

SPECIALIZED TRAINING, CERTIFICATION OR EXPERIENCE

TRAINING/CERTIFICATION

First Aid

Expiration Date

Additional Comments

TRAINING/CERTIFICATION

CPR

Expiration Date

Additional Comments

TRAINING/CERTIFICATION

AED

Expiration Date

Additional Comments

TRAINING/CERTIFICATION

Medication Administration

Expiration Date

Additional Comments

TRAINING/CERTIFICATION

Crisis Intervention

Expiration Date

Additional Comments

TRAINING/CERTIFICATION

Defensive Driving

Expiration Date

Additional Comments

TRAINING/CERTIFICATION

Bloodborne Pathogens

Expiration Date

Additional Comments

TRAINING/CERTIFICATION

Other

Expiration Date

Additional Comments

WORK HISTORY

If you are currently employed, may we contact your employer?

Yes

Begin with Current or Most Recent Employer or Position with Employer

Employer

Address

Phone Number

Supervisor

Dates Of Employment

Ending Wage

Position

Description of Job

Reason For Leaving

Employer 2

Address

Phone Number

Supervisor

Dates Of Employment

Ending Wage

Position

Description of Job

Reason For Leaving

REFERENCES

Serenity requests that all applicants submit (2) references, which may include: current of former employers, supervisors, teachers or others qualified to objectively evaluate your ability to work in the position for which you have applied. Please list the reference information identified below. Serenity will be contacting each reference listed.

Name

Relationship to Applicant

Address

Fax Number

Daytime Phone Number

Nighttime Phone Number

Name 2

Relationship to Applicant

Address

Fax Number

Daytime Phone Number

Nighttime Phone Number

Applicant Declaration of Understanding

I understand that Serenity Day Habilitation may conduct and investigate of the information I have noted on this application by contacting my prior employer and references.

I understand that any falsification, misrepresentation or omission of information discovered as a result of this investigation may terminate the employment process or if hired, may subject me to the immediate termination of my employment with Serenity Day Habilitation.

I understand that by signing below, Serenity Day Habilitation will check the child and /or adult abuse registries as well criminal records check. The post-employment discovery of conviction information not provided here will subject me to the disciplinary policy. This will likely result in termination of my employment.

I understand that before I may be allowed to drive on agency business vehicle, a driving records check will be conducted.

I understand that nothing contained in this application should be considered as a contract of employment.

I acknowledge that I am an employee at will.

Applicant Signature

Clear

Date

Employee Background Check Required Information

The following named individual has made an application with Serenity Day Habilitation for Employment

Last Name

First Name

Middle Name

Date of Birth

Social Security Number

Alias or Former Name

Current Address

Telephone Number

Driver’s License Number

State

Expiration Date

Male or Female

I authorize the FBI and New Jersey Division of Criminal Investigation to disclose all criminal history record information to All Serenity Day Habilitation for the purpose of employment as specified above.

The expiration of this authorization shall be for a period of one year from the date of my signature.

Consent Signature

Clear

Date

Mental Retardation/Development Disability	Seizure	Deaf/Hearing Impairments
Muscular Dystrophy	Catheter Care	Asthma/Breathing Difficulty
Cerebral Palsy	Nebulizer Treatment	Memory Impairments/AlzheimerParalysis: Para/Quadriplegia
Bowel Program	Feeding Tubes	Mental Health Issues
Gastrostomy	Vision Impairments/Blind	Other