Employment Application

Direct Support Professional (DSP)

Please complete all applicable sections. Fields marked with * are required.

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Personal Information

First Name * Middle Name Last Name * Preferred Name Email * Phone * Street Address * City * State * ZIP Code *

Position & Availability

Position Applying For * Date Available to Start * Desired Hours Per Week Employment Type

Days Available

Shifts Available

Transportation

Do you have a valid driver's license? * Do you have reliable transportation? * Are you willing to transport clients if required? Do you currently have automobile insurance?

Qualifications & Training

Highest Level of Education CPR / First Aid Current? TB Test Current? Medication Administration Training?

Relevant Certifications / Training Describe your experience supporting individuals with developmental or intellectual disabilities. Describe your experience with personal care, behavior support, community integration, documentation, or medication assistance.

Employment History

List your most recent employers first.

Employer 1

Employer Name Phone Job Title Supervisor Start Date End Date

Reason for Leaving Key Duties

Employer 2

Employer Name Phone Job Title Supervisor Start Date End Date

Reason for Leaving Key Duties

Employer 3

Employer Name Phone Job Title Supervisor Start Date End Date

Reason for Leaving Key Duties

Professional References

Reference 1 Name Reference 1 Phone Reference 1 Relationship Reference 1 Email Reference 2 Name Reference 2 Phone Reference 2 Relationship Reference 2 Email Reference 3 Name Reference 3 Phone Reference 3 Relationship Reference 3 Email

Job Requirements

Are you at least 18 years old? * Are you legally authorized to work in the United States? * Will you now or in the future require employment sponsorship? Have you previously worked for this organization?

If yes, provide dates and position.

Background Screening Acknowledgment

This application does not request your Social Security number or detailed criminal-history information. If you advance in the hiring process, any required background check should be handled through a separate, compliant authorization and disclosure process.

I understand that employment may be contingent upon satisfactory completion of legally permitted background checks, reference checks, and credential verification.

Applicant Certification

I certify that the information in this application is true and complete to the best of my knowledge. I authorize the organization to verify the employment, education, references, licenses, and certifications I have provided, as permitted by law. I understand that submitting this application does not create a contract of employment.

Electronic Signature (Type Full Legal Name) * Date *