Safe Transitions
APPLICATION FOR EMPLOYMENT
Fields marked with * are required.
SECTION 1: PERSONAL INFORMATION
First Name * Middle Name * Last Name *
 
Address *  
City * State * Zip *
E-mail Address * Phone *
 
Are you eligible to work in the United States? * Yes No  
If you are under age 18, do you have an employment/age certificate? Yes No  
Have you been convicted of or pleaded no contest to a felony within the last five years? * Yes No
 
SECTION 2: POSITION/AVAILABILITY
Position Desired:
Days Available: Monday   Tuesday   Wednesday   Thursday   Friday   Saturday   Sunday  
Hours available: to 
Available Starting Date:   , 
SECTION 3: EDUCATION
History-Please include name & address of school - Degree/Diploma - Graduation Date
School Name Degree
  , 
School Address Graduation Date
 
Skills and Qualifications:
Licenses, Training, Awards
SECTION 4: EMPLOYMENT HISTORY
Present or Last Position
Most Recent Employer City State
Position TitleSupervisorSupervisor Phone #
Supervisor E-mailAnnual Salary
,  ,  Currently employed? Yes  No
Employment Start Date Employment End Date
Responsibilities:  
Reason for leaving: 
May we contact your most recent employer? Yes  No
Previous Position #1
Previous Employer City State
Position Title Supervisor Supervisor Phone #
Supervisor E-mail Annual Salary
,  ,   
Employment Start Date Employment End Date  
Responsibilities:  
Reason for leaving: 
References
Reference #1 *Reference #2 *Reference #3 *
Address #1 * Address #2 * Address #3 *
Phone #1 *Phone #2 *Phone #3 *
Do you have a valid driver's license? Yes No
Do you have a high school diploma or equivalent? Yes No
Can you pass a criminal background check? Yes No
If no, please explain:
Is there any reason you can not work with Vulnerable Adults or Children? Yes No
If yes, please explain:
Do you have a clean driving record? Yes No
If no, please explain:
I certify that information contained in this application is true and complete.

I understand that false information may be grounds
for not hiring me or for immediate termination of
employment at any point in the future if I am hired.
I authorize the verification of any or all information listed above.

After clicking 'Verify' you will be shown your application for verification.
If incorrect, please use your browser's back button to correct your application.
If correct, please click the appropriate link at the bottom of the next page.