Job Application - Agape Home of Indiana

📋 Open Positions ▼

We are currently hiring for:

Care Coordinator
Direct Support Professional

Have you worked in a similar role before?

Yes No

✅ Employment Eligibility ▼

Select Job Position

Care Coordinator Direct Support Position

Are you a U.S. Citizen?

Yes No

If NO, are you allowed to work in the U.S.?

Yes No

Have you ever worked for this employer?

Yes No

If YES, number of years:

Have you ever been convicted of a felony?

Yes No

If YES, please explain:

👤 Personal Information ▼

Full Name

Email Address

Phone Number

Street Address

City

State

Zip Code

Date of Birth

Social Security Number

Your information is kept confidential

Date Available to Start

Desired Pay ($)

Pay Option

Hourly Salary

Employment Desired

Full-Time Part-Time Seasonal

🎓 Education ▼

High School

High School Name

City / State

From

To

Did you graduate?

College/Diploma

College Name

City / State

From

To

Did you graduate?

Degree

College/University Name

City / State

From

To

Did you graduate?

💼 Employment History ▼

Employer 1

Company Name

Phone

Email

Address

City

State

Zip Code

Job Title

Starting Date

Ending Date

Starting Pay ($)

Pay Option

Hourly Salary

Responsibilities

Employer 2 (Optional)

Company Name

Phone

Email

Address

City

State

Zip Code

Job Title

Starting Date

Ending Date

Responsibilities

Employer 3 (Optional)

Company Name

Phone

Email

Job Title

Starting Date

Ending Date

Responsibilities

👥 References ▼

Reference 1

Full Name

Relationship

Company Name

Title

Phone

Email

Reference 2

Full Name

Relationship

Company Name

Title

Phone

Email

🎖️ Military Service ▼

Are you a veteran?

Yes No

Branch

Rank at Discharge

Service Start Date

Service End Date

Type of Discharge

If not honorable, please explain:

🔒 Background Check Consent ▼

Are you willing to consent to a background check if requested?

Yes No

Signature (Print Full Name)

By typing your name, you are electronically signing this application

📄 Terms & Conditions ▼

Disclaimer:

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.

I have read and agree to the terms and conditions

Job Application Form

📋 Open Positions ▼

✅ Employment Eligibility ▼

👤 Personal Information ▼

🎓 Education ▼

High School

College/Diploma

Degree

💼 Employment History ▼

Employer 1

Employer 2 (Optional)

Employer 3 (Optional)

👥 References ▼

Reference 1

Reference 2

🎖️ Military Service ▼

🔒 Background Check Consent ▼

📄 Terms & Conditions ▼