Job Application - Agape Home of Indiana

Position & Eligibility

We are currently hiring for Care Coordinator and Direct Support Professional positions.

Select Position *

Have you worked in a similar role before? *

Yes No

Are you a U.S. Citizen? *

Yes No

Are you authorized to work in the U.S.? *

Yes No

Have you ever worked for Agape Home before?

Yes No

Number of years:

Have you ever been convicted of a felony? *

Yes No

Please explain: *

Personal Information

Your information is kept confidential and secure.

Full Name *

Email Address *

Phone Number *

Street Address *

City *

State *

Zip Code *

Date of Birth *

Social Security Number *

Date Available to Start *

Desired Pay ($) *

Pay Option *

Employment Type *

Education History

High School

School Name *

City / State *

From *

To *

Did you graduate? *

Yes No

College (Optional)

College Name

City / State

From

To

Did you graduate?

Yes No

University / Degree (Optional)

University Name

City / State

Degree

Did you graduate?

Yes No

Employment History

Most Recent Employer

Company Name *

Phone *

Email *

Address *

City *

State *

Zip Code *

Job Title *

Start Date *

End Date *

Starting Pay ($) *

Pay Option *

Responsibilities *

Previous Employer 2 (Optional)

Company Name

Phone

Email

Job Title

Start Date

End Date

Responsibilities

Previous Employer 3 (Optional)

Company Name

Phone

Email

Job Title

Start Date

End Date

Responsibilities

References

Reference 1

Full Name *

Relationship *

Company *

Title *

Phone *

Email *

Reference 2

Full Name *

Relationship *

Company *

Title *

Phone *

Email *

Military Service

Are you a veteran? *

Yes No

Branch *

Rank at Discharge *

Service Start Date

Service End Date

Type of Discharge *

Please explain:

Review & Submit

Are you willing to consent to a background check? *

Yes No

Terms & Conditions

I certify that my answers are true and honest to the best of my knowledge.

If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

Electronic Signature (Type your full name) * By typing your name, you are electronically signing this application

I have read and agree to the terms and conditions *