Social Service Solutions, Inc

Job Application Form

If you are considered for an interview you will be required to complete a full application. At the time of such interview, candidates will also be asked to provide the complete addresses and phone numbers for three professional references which are to include current or previous supervisors. This cannot include friends, family or co-workers.

This form must be filled out completely. Fields with bold labels are required.

Name:
Street Address:
Address (cont'd):
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:
Today's Date:
Are you eligible to work in the USA?	Yes No
Have you ever received a felony conviction?	Yes No
Do you have a valid Minnesota driver's license?	Yes No
Will you consent to a pre-employment background and driving record check?	Yes No
Do you have reliable transportation and are you willing to travel within the Twin Cities metro area?	Yes No
Are you able to lift up to 50lbs?	Yes No
Do you have previous experience working with individuals with Development Disabilities?	Yes No
If yes, for approximately how many years?
Do you have previous experience working with individuals with Severe and Persistent Mental Illness?	Yes No
If yes, for approximately how many years?
Do you have one of the following degrees?	Bachelor of Science or Arts in Human Services or related field Associate of Science in Human Services No
Are you currently employed?	Yes No
When are you available to work? (Check all that apply.)	Days (7am-3pm) Evenings (3pm-10pm) Awake Overnights (10pm-8am) Weekends
Date you can begin employment?
Number of hours a week you are available to work?
Are you currently certified in:	CPR First Aid
Have you received training in Medication Administration and able to provide documentation?	Yes No
How did you hear about us?
If an employee or associate of this company referred you to us, please provide their name:
Please give us a brief description of your experiences. Describe education, training, certifications, employment and volunteer work. Also list your reasons for applying with Social Service Solutions.
Attach résumé:
By submitting this brief application you declare that all of the information is true. Social Service Solutions will verify all the information that you provide to us in the application process. Candidates / employees who provide false information may be subject to discharge.
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