Employment Application

Employment Application
Applicant Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you 18 or older?
Do you have a high school diploma?
Are you a citizen of the United States?
If no, are you authorized to work in US?
Do you have a valid driver's license?
Do you have a clean driving record?
Do you have 1 year of experience in the disability or related caregiving fields?
Have you ever been charged, convicted, pled nolo contendere or had adjudication withheld of a felony or misdemeanor?
If yes, please explain:

Employment Experience
Applicant Name

First NameLast Name
Current Employer
Company Name
Employment Dates
Position
Ending Salary
Annual or hourly
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor

First NameLast Name
Supervisor Phone Number
Please enter a valid phone number.
Supervisor Email
example@example.com
By signing below I am consenting to allow Adult Care Housing to check my employment reference.
Signature
Reference

Employment Experience
Applicant Name

First NameLast Name
Current Employer
Company Name
Employment Dates
Position
Ending Salary
Annual or hourly
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor

First NameLast Name
Supervisor Phone Number
Please enter a valid phone number.
Supervisor Email
example@example.com
By signing below I am consenting to allow Adult Care Housing to check my employment reference.
Signature
Reference

Employment References Must Include 2 previous employers and cover a minimum of 2 years. Please add addition employment experience if needed.
Employment Experience
Applicant Name

First NameLast Name
Current Employer
Company Name
Employment Dates
Position
Ending Salary
Annual or hourly
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor

First NameLast Name
Supervisor Phone Number
Please enter a valid phone number.
Supervisor Email
example@example.com
By signing below I am consenting to allow Adult Care Housing to check my employment reference.
Signature

Employment References Must Include 2 previous employers and cover a minimum of 2 years. Please add addition employment experience if needed.
Employment Experience
Applicant Name

First NameLast Name
Current Employer
Company Name
Employment Dates
Position
Ending Salary
Annual or hourly
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor

First NameLast Name
Supervisor Phone Number
Please enter a valid phone number.
Supervisor Email
example@example.com
By signing below I am consenting to allow Adult Care Housing to check my employment reference.
Signature

Personal Reference

People that have known you for 3 years or more, no relatives or spouses.
Applicant Name

First NameLast Name
Reference Name*

First NameLast Name
How long have you known this person?*
Relationship to Reference
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
By signing below I am consenting to allow Adult Care Housing to check my reference.
Signature*
Reference

Personal Reference

People that have known you for 3 years or more, no relatives or spouses.
Applicant Name

First NameLast Name
Reference Name*

First NameLast Name
How long have you known this person?*
Relationship to Reference
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
By signing below I am consenting to allow Adult Care Housing to check my reference.
Signature*
Reference

Personal Reference

People that have known you for 3 years or more, no relatives or spouses.
Applicant Name

First NameLast Name
Reference Name*

First NameLast Name
How long have you known this person?*
Relationship to Reference
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
By signing below I am consenting to allow Adult Care Housing to check my reference.
Signature*
Office Email
example@example.com

Required Training

APD requires the following training. Please submit anything that is current. If you don't have any of it, it is ok, we will help you. :)
Classes in Train

Zero Tolerance (5 Modules)
https://fl.train.org/florida/course/1111689/details
APD - Requirements for All Waiver Providers
https://fl.train.org/florida/course/1104869/details
APD - Health Insurance Portability and Accountability Act (HIPAA) Basics
https://fl.train.org/florida/course/1111685/details
APD - Direct Care Core Competencies (5 Modules)
https://fl.train.org/florida/course/1111679/details
FDOH HIV/AIDS 101 In the News
https://fl.train.org/florida/course/1059884/details

Other Courses

Medication Administration: Initial Full Certificate
Medication Admin: Initial Basic Med Validation
Medication Admin: Current Basic Med Validation
Medication Admin: Train Recert
PCM Initial Full
PCM Recertification
Behavior Assistant Initial Full
Behavior Assistant Recertification
CPR/1st Aid
Upload any current certificates or training.

Cancelof
By signing below, I certify that all the information is true and correct to the best of my knowledge.

Clear
Should be Empty:

Education