The Daybreak Group, Home and Community Services, in home supports, provider of residential services for individuals with developmental disabilities

Employment Opportunities

Online Employment Form

Foster Care Opportunities

Online Foster Care Application

Online Employment Form

To print the application click here

Personal Information

First Name:
Middle Name:
Last Name:
Current Address:
City:
State:
Zip Code:
Previous Address:
City:
State:
Zip Code:
Home Phone:
Business Phone:

Do you have any relatives currently employed with Daybreak or serving as a board member?
Yes No

If yes, please list name(s) and relationship(s):

Referral Source:

AVAILABILITY

Position you are applying for:	Have you worked here previously? Yes No
Category you prefer?
What date can you start?
What schedule are you available to work? Other?

JOB RELATED SKILLS
NOTE: Complete only those questions in this section that are job-related

	Name on Driver’s License:
Last Name:
First Name:
Middle Name:

Have you had any moving violations within the last seven years? Yes No

If yes, please describe

Professional License(s)

Description:
Number:
Issued by:
Valid dates:

What business equipment can you operate? (fax, copier, etc.)

List computer software programs you are proficient in:

SECURITY

List states and counties of residence for the past seven years:

Have you ever used any names other than given above? Yes No

If so, please list:

Have you ever been convicted of a crime (misdemeanor and felony)? Yes No

If yes, please describe below. Please note: Falsification or omission of information regarding a conviction is a terminable offense. (A conviction will not necessarily bar you from employment. In accordance with company policy and applicable state and federal laws, factors such as age at time of offense, remoteness of the offense, time since last conviction, nature of job sought and rehabilitation effort will be reviewed.)

Date of Incident	City	State	Charge

Have you ever been discharged or asked to resign because of unsatisfactory conduct or performance of duties?
Yes No

If yes, please explain:

Have you ever been found to be the perpetrator of a confirmed Class I Abuse in previous employment?
Yes No

If yes, please explain:

COMMENTS

EMPLOYMENT HISTORY

Please note: Your application will not be considered unless every question in this section is answered. Falsification or omission of previous employers may bar your employment with Daybreak. Please list employment history for a minimum of 5 years. Use the back of the application to provide further employment history if necessary.

Job Title & Dates of Employment

Name & Address of Employer

Beginning & Ending Salary

Job Duties, Supervisor &
Reason for Leaving

Most Recent Job
Job Title

Employment Dates

From

Company Name

City

State
Zip
Phone

Beginning Salary

per

Ending Salary

per

Job Duties

Supervisor

Reason for Leaving

Next Most Recent Job
Job Title

Employment Dates

From

Company Name

City

State
Zip
Phone

Beginning Salary

per

Ending Salary

per

Job Duties

Supervisor

Reason for Leaving

Next Most Recent Job
Job Title

Employment Dates

From

Company Name

City

State
Zip
Phone

Beginning Salary

per

Ending Salary

per

Job Duties

Supervisor

Reason for Leaving

Any additional job references please include same criteria as above.

Education

Name of School	City/State	Graduated	Degree
High School:	/	Yes No
College:	/	Yes No
Other:	/	Yes No
Other:	/	Yes No

Additional Information

AN EQUAL OPPORTUNITY EMPLOYER

CERTIFICATION AND RELEASE Please read the following statements carefully.

In consideration of my employment, I agree to conform to the policies and procedures of the company. I understand that in accepting this application, Daybreak is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time.

I certify that the answers given by me on this application for employment are true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment.

I authorize Daybreak and/or its agents, including consumer-reporting bureaus, to verify any of this information. I authorize former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I also understand that the use of illegal drugs, alcohol and inhalants is prohibited during employment. If Company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs, alcohol or inhalants prior to and during employment.

I have read and understand the above. By clicking "I Accept" you are sending your application to Daybreak and the information contained herein will be used for the consideration of your employment and you accept the terms stated in this application.

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