Employment Application

Email
This field is for validation purposes and should be left unchanged.
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Position
Phone*
Msg. Phone
Select preferred
- Text
- Call
- Either
Email Address*
Are you at least 18yrs old?*
- Yes
- No
High School Diploma or GED?
Must provide
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Employment history (including volunteer) beginning with most recent employment:
Firm
Address
Street Address Address Line 2 City State ZIP Code
Employment Date Start
Employment Date End
Position
Duties
Supervisor
Phone Number
Reason for leaving
May we contact
- Yes
- No
Firm
Address
Street Address Address Line 2 City State ZIP Code
Employment Date Start
Employment Date End
Position
Duties
Supervisor
Phone Number
Reason for leaving
May we contact
- Yes
- No
Firm
Address
Street Address Address Line 2 City State ZIP Code
Employment Date Start
Employment Date End
Position
Duties
Supervisor
Phone Number
Reason for leaving
May we contact
- Yes
- No

High School or GED Contact
School*
Address
Street Address Address Line 2 City State ZIP Code
Course of Study
Years Completed*
Year Graduated*
College
Address
Street Address Address Line 2 City State ZIP Code
Course of Study
Years Completed
Diploma / Degree
College
Address
Street Address Address Line 2 City State ZIP Code
Course of Study
Years Completed
Diploma / Degree

Personal References
Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Occupation*
Length of Time Known*
Phone*
Personal References
Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Occupation*
Length of Time Known*
Phone*
Personal References
For the purpose of avoiding a Conflict of Interest in employment, do you have a family member or close friend who receives services from VRS or is employed by VRS? If so, whom?*
Please note that your answer regarding a potential Conflict of Interest does not preclude your employment at VRS, but may affect the exact work location you may be placed in. Agency policies will not allow you to be supervised by a family member/close friend or work in the same residence as a family member.
Additional Information
Have you ever been disciplined or fired?*
- Yes
- No
If yes, please explain
Have you ever been convicted of a felony or released from prison during the last 7 years?*
- Yes
- No
If yes, please explain
Do you have a valid driver's license?*
- Yes
- No
Have you had two or more traffic violations during the last 3 year period?*
- Yes
- No
If yes, please explain

Employment status
What is your current employment status?*
Please list the hours you WOULD be available.*
Please list the hours you WOULD NOT be available.*
Available work shifts (please check all which apply)*
- Full-time
- Part-time
- On-call
- Nightshift
- Evenings
- Weekdays
- Weekends
May we contact you at your place of employment?
- Yes
- No

VRS management utilizes Facebook and Facebook Messenger for communication with staff regarding general agency-wide memos, notices of upcoming training, reminders of medical appointments/activities, individual house groups, craft & cooking class groups, etc. All staff will be required to have and maintain either a personal Facebook account or to create a work-only Facebook account, to join the Valley Residential Services employee Facebook groups. If you do not have access to the internet, there is a desktop computer available at the office through which you may access the VRS Facebook page. IT IS YOUR RESPONSIBILITY TO CHECK THE VRS FACEBOOK PAGE A MINIMUM OF ONCE WEEKLY FOR IMPORTANT NOTICES. Signing and submitting this application signifies your acknowledgment and agreement with this policy.

The information I have given in this application is, to the best of my knowledge, accurate and truthful. I understand that falsifying this application is grounds for disqualification from consideration or termination if employed.
Applicant Print Name*
First Last
Applicant Signature*
Date
MM slash DD slash YYYY

Please respond to the following questions
What is your philosophy regarding the care and training of the developmentally disabled?*
What is your philosophy regarding the human and civil rights of the developmentally disabled?*

DRUG-FREE WORKPLACE POLICY
PLEASE READ AND SIGN THIS FORM

Valley Residential Services maintains that an alcohol and drug-free workplace is necessary for the safety of clients, employees, and the general public. VRS recognizes alcohol and drug dependency as an illness and a major health problem. However, the presence of alcohol and/or drugs in the workplace constitutes a safety risk and will not be tolerated.

Employment with VRS will be contingent upon the satisfactory result of a drug test before hiring. All employees may be subject to random alcohol/drug testing without cause. The cost of testing will be paid by the agency. All results will be held strictly confidential.

This policy is not intended to violate individual rights. It is intended to provide for an alcohol and drug-free environment that promotes safety and enhances the performance of the responsibilities assigned to employees. A complete copy of the VRS drug-free workplace policy is available at the administrative office.

IF YOU DO NOT WANT TO TAKE THIS PRE-EMPLOYMENT TEST YOU SHOULD WITHDRAW YOUR APPLICATION.

I hereby give my consent to any doctor, technician, hospital, VRS manager, or testing laboratory to conduct the required drug testing (including my giving of a urine specimen) and to have the drug test results be released to Valley Residential Services.
Applicant Print Name*
First Last
Applicant Signature*
Date
MM slash DD slash YYYY

STATEMENT OF EQUAL OPPORTUNITY
Valley Residential Services intend to employ the most suitable qualified persons available. The tenure of every employee shall depend upon the need of the work performed, the availability of funds, effective performance, good conduct, and continuing fitness for the position. Each employee shall be expected to perform at an optimal level.

Equal opportunity employment will assure that no appointment, promotion, dismissal, or discipline affecting any position in the agency shall be influenced negatively because of race, color, creed, religion, national origin, age, gender, presence of any sensory, mental or physical disability, including HIV/AIDS conditions, use of a trained guide dog or service animal by a person with a disability, marital status, disability status or Vietnam era status, sexual orientation, gender identity/presentation, or any other reason prohibited by law.

Valley Residential Services will provide qualified applicants and employees with disabilities with reasonable accommodations that do not impose an undue hardship.

If you believe you have been discriminated against you may file a complaint with the Valley Residential Services Affirmation Action Officer or contact an Equal Employment Opportunity Commission field office by calling 1-800-669-3362.

Consent for Reference Check
Valley Residential Services has my consent to contact my previous employers and personal references.
Signature*
Print Name*
First Last
Date
MM slash DD slash YYYY

AUTHORIZATION FOR BACKGROUND INQUIRY
I hereby authorize Valley Residential Services to request information relating to my background. I understand that such inquiry may be to federal and/or state law enforcement agencies, that I will be notified of each response, and that a copy of each response will be available to me upon request.

I attest, under penalty of perjury, that the information I have provided on the attached Disclosure Statement is true and accurate to the best of my knowledge.
Signature of Applicant*
Printed Name of Applicant*
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Date
MM slash DD slash YYYY

Valley Residential Services

Online Application

Step 1 of 13

Employment history (including volunteer) beginning with most recent employment:

High School or GED Contact

Personal References

Personal References

Personal References

Additional Information

Employment status

Please respond to the following questions

DRUG-FREE WORKPLACE POLICY

STATEMENT OF EQUAL OPPORTUNITY

Consent for Reference Check

APPLICANT DISCLOSURE STATEMENT

REQUEST FOR INFORMATION

AUTHORIZATION FOR BACKGROUND INQUIRY