Employment Application

Employment Application

What position(s) are you you applying for?*

—Please choose an option—HousekeeperDay Program ManagerDirect Support ProfessionalCommunity RN

Personal Information

First Name*

Middle Name*

Last Name*

Have you worked or earned a degree under any other names?*

—Please choose an option—YesNo

List all other names or write in N/A if none*

Email Address*

Phone Number*

Address*

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Date of Birth*

Avant Supported Living is an equal opportunity employer and does not discriminate due to an applicant’s age. We require this information in order to ensure all applicants are at least 18 years of age and to complete a comprehensive background screening as mandated by the Missouri Department of Mental Health.

Have you registered with the Family Care Safety Registry?*

If you have not registered, please register here.

—Please choose an option—YesNo

Have you ever applied for an Exception or Good Cause Waiver?*

—Please choose an option—Yes, I was previously granted an Exception or Good Cause Waiver (A new Exception letter will need to be obtained if you are offered a position.)I have previously applied for an Exception or Good Cause Waiver but was denied.No, I have never applied for an Exception or Good Cause Waiver.

Do you have all of the required items listed above before applying?*

—Please choose an option—Yes, I have my Driver License, Social Security card, proof of education, and proof of current auto insurance.I have some of the items, but not all of them (not eligible for consideration).

Have you previously applied for employment with Avant?*

—Please choose an option—YesNoI don't rememberI am a former employee who resignedI am a former employee who was terminated

How were you referred to Avant?*

—Please choose an option—Website searchWalk-inSocial mediaJob fairAd in newspaperIndeedEmployee referral (list name in next questionOther (list in next question)

If you checked “employee referral” or “other” in the previous question, tell us here how you were referred to Avant. Enter none or N/A if not checked above.*

PERTINENT INFORMATION

Are you able to perform the specific duties of the position for which you are applying?*

—Please choose an option—YesNo

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

—Please choose an option—YesNo

Some positions may require you to obtain a Class E Missouri license. Do you have, or are you willing to obtain a Class E license?*

—Please choose an option—YesNo

EDUCATION

What is your level of education?*

The Missouri Department of Mental Health requires a minimum of a high school diploma or GED/HiSET certificate to be employed in this field. We verify!

—Please choose an option—High SchoolGED/HiSETSome collegeAssociates degreeBachelor degree or higher

Name of High School*

City and State of High School*

High School Graduation Year*

Name of college, university, or trade school

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Major or primary field of study.

Did you graduate?

—Please choose an option—YesNoStill attending

College graduation year or last year attended

CERTIFICATIONS

Please Check all of the certifications you hold:

CPR/First AidLevel 1 Med AideCPI (Crisis Prevention Intervention)CNATools of ChoiceNone of the above

Do you have any other skills, certifications, or licenses you would like us to consider?

EMPLOYMENT HISTORY

Who is your current or most recent employer?*

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your title or position:*

Who can verify your employment and what is their phone number?*

Start date*

End date (leave blank if you are still with this employer).

What is your status with this employer?*

None SelectedI am currently employed but looking to make a changeI am currently employed and looking for supplemental hoursI resigned and I am not currently employedI was terminatedOther (explain below)

Please explain if you selected “other” above.

Do you agree that we can verify the above information with this employer?*

None SelectedYesNo

Previous Employer

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your title or position:

Who can verify your employment and what is their phone number?

Start date

End date (leave blank if you are still with this employer).

What is your status with this employer?

None SelectedI am currently employed but looking to make a changeI am currently employed and looking for supplemental hoursI resigned and I am not currently employedI was terminatedOther (explain below)

Please explain if you selected “other” above.

Do you agree that we can verify the above information with this employer?

None SelectedYesNo

Previous Employer

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your title or position:

Who can verify your employment and what is their phone number?

Start date

End date (leave blank if you are still with this employer).

What is your status with this employer?

None SelectedI am currently employed but looking to make a changeI am currently employed and looking for supplemental hoursI resigned and I am not currently employedI was terminatedOther (explain below)

Please explain if you selected “other” above.

Do you agree that we can verify the above information with this employer?

None SelectedYesNo

Previous Employer

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your title or position:

Who can verify your employment and what is their phone number?

Start date

End date (leave blank if you are still with this employer).

What is your status with this employer?

None SelectedI am currently employed but looking to make a changeI am currently employed and looking for supplemental hoursI resigned and I am not currently employedI was terminatedOther (explain below)

Please explain if you selected “other” above.

Do you agree that we can verify the above information with this employer?

None SelectedYesNo

Previous Employer

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your title or position:

Who can verify your employment and what is their phone number?

Start date

End date (leave blank if you are still with this employer).

What is your status with this employer?

None SelectedI am currently employed but looking to make a changeI am currently employed and looking for supplemental hoursI resigned and I am not currently employedI was terminatedOther (explain below)

Please explain if you selected “other” above.

Do you agree that we can verify the above information with this employer?

None SelectedYesNo

Have you entered into a non-compete agreement with any current or former employers that is still in effect?*

—Please choose an option—YesNo

Have you ever quit a job without notice or failed to complete all of your assigned shifts after you gave notice?*

—Please choose an option—YesNo

How many days of work have you missed in the last year?*

Please explain any gaps between employers here.*

REFERENCES

Reference name (do not enter family members).*

Occupation

How do you know this person?*

—Please choose an option—Current or former supervisorCurrent or former co-workerCurrent or former teacherFriend

Phone Number*

Reference name (do not enter family members).*

Occupation

How do you know this person?*

—Please choose an option—Current or former supervisorCurrent or former co-workerCurrent or former teacherFriend

Phone Number*

Reference name (do not enter family members).*

Occupation

How do you know this person?*

—Please choose an option—Current or former supervisorCurrent or former co-workerCurrent or former teacherFriend

Phone Number*

MILITARY SERVICE

Are you eligible under Protected Veterans status?*

—Please choose an option—YesNo

Branch

From:

To:

Rank at discharge

—Please choose an option—HonorableGeneral DischargeOther than Honorable Conditions DischargeBad Conduct Discharge (BCD)Dishonorable DischargeOfficer DischargeEntry Level Separation (ELS)

If other than honorable, please explain:

TRANSPORTATION / CHILDCARE

Do you have your own vehicle?*

—Please choose an option—Yes, I have my own carYes, I have my own car but I prefer not to use it to transport consumersI use someone else's carI do not have a car and depend on someone else to bring me to workI do not have a car and use public transportation

Do you have and maintain current auto insurance on this vehicle?*

—Please choose an option—Yes, I provide insurance on this vehicleYes, someone else provides insurance on this vehicleNo, I do not have current auto insurance

Do you have reliable childcare?*

—Please choose an option—YesI do not have any children in need of childcare

AVAILABILITY

If offered a position, when can you start?*

What is your availability? Check all that apply.*

DaytimeMorningAfternoonEveningOvernight (awake)WeekdaysWeekendsHolidays

How many hours per week are you seeking to work?*

PRN (on call)8-1616-2424-3232-40

DOCUMENTATION

We are required to provide clear, concise, detailed, and accurate documentation as stipulated in our contract with the Missouri Department of Mental Health. We will train you if this is something you have not done before, but to give us an indication of your ability, please provide a concise and chronological account of your day up to this point.*

Have you used Therap software previously?*

—Please choose an option—YesNo

TRAINING

If offered a position, do you agree to attend all training classes as required by the Missouri Department of Mental Health? Completing all state-mandated training is a condition of employment.*

I agree to make all necessary arrangements with school and/or other employers in order to attend. I further understand that failure to attend could affect my offer of employment.I cannot attend all of the required training classes.

ELECTRONIC SIGNATURE AND AGREEMENT

I hereby certify that all of the information entered on this application is complete, accurate, and true. I understand that submitting an application and receiving notification of a preliminary background screening does not guarantee I will be called for an interview or offered a position. I understand that this application is not a contract of employment. I understand that in the state of Missouri any potential employment is “at will” and can be terminated with or without notice at any time, for any reason, or for no reason. I understand there is a 60 day probationary period for all employees, which may be extended at the discretion of Avant Supported Living. I understand that I am giving Avant Supported Living permission to complete a background check using my full name, Social Security number, and date of birth, and any potential offer of employment is contingent upon passing a thorough background screening. I understand that any false or misleading statements on this application may affect any potential offer of employment or result in dismissal if found after employed. By entering my full name below, I certify that I understand my electronic signature is the legal equivalent of my manual signature on this application.*

If you do not see an acknowledgement page after you press SUBMIT, your application has not been processed. Please scroll up and complete any missing information in sections marked with an asterisk (*), which denotes that a response is required.

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