Maxabilities.org | Employment Application

Personal Information
Date*
Name*
First Last
Phone*
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Job you are applying for*
- Direct Support Professional
- Job Coach
- Case Manager
- Respite Workers
- Licensed Practicing Nurse
- CTA House Manager
Referred By*
Do you have a valid driver's license?*
- Yes
- No
Driver's License Number*
State*
Expiration Date*

Desired Employment
Desired Employment Position*
Desired Position Schedule*
- Part Time
- Full Time
- Shift
Are you currently employed?*
- Yes
- No
Date Available*
Desired Salary*
List all qualifications you have essential to the position*
Please write a paragraph telling us why you would like to work for York County Board DSN.*

High School Name*
High School Location*
Did you graduate?*
- Yes
- No
College Name*
College Location*
Major*
Did you graduate?*
- Yes
- No
Degree Received*
Other College Name
Other College Location
Other College Major
Did you graduate?
- Yes
- No
Degree Received
Subjects of Special Study or Research Work*

References
Reference #1 Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship*
Reference #2 Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship*
Reference #3 Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship*

Employment History
List below your three most recent employers, starting with your present or last employer. List under company name any periods of employment. If you were employed under another name, please enter it under the company name. EXPLAIN ALL GAPS IN EMPLOYMENT (Gaps in any employment date must be explained below).
Company/Agency #1 Name*
From*
To*
Rate of Pay: Starting Pay and Final Pay*
Title of Job Held*
Supervisor's Name*
Company/Agency Phone Number*
Company/Agency Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reason for Leaving*
Company/Agency #2 Name
From
To
Rate of Pay: Starting Pay and Final Pay
Title of Job Held
Supervisor's Name
Company/Agency Phone Number
Company/Agency Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reason for Leaving
Company/Agency #3 Name
From
To
Rate of Pay: Starting Pay and Final Pay
Title of Job Held
Supervisor's Name
Company/Agency Phone Number
Company/Agency Phone Number
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reason for Leaving
Are you authorized to work in the United States?
- Yes
- No
If currently employed, may we contact your employer?
- Yes
- No
Have you been discharged for misconduct or unsatisfactory service or forced to resign from any organization?
- Yes
- No
If yes, please explain.*
Have you ever been previously employed by this agency?
- Yes
- No
If yes, why did you leave?*
Last Date of Employment with Our Agency:*
Explain any gaps in employment.*
Describe your job responsibilities for your last job, or current job if you are still employed.*
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Employment Application

York County Board of Disabilities and Special Needs Employment Application

Step 1 of 6

Personal Information

Desired Employment

References

Employment History

Please read and sign the following:

Quick Links

Contact

Employment Application

York County Board of Disabilities and Special Needs Employment Application

Step 1 of 6

Personal Information

Desired Employment

References

Employment History

Please read and sign the following:

Quick Links

Employee Log In

Contact