Shared Living Provider Application : Join Our Team : Developmental Education & Behavioral Outcomes

SHARED LIVING PROVIDER APPLICATION

Developmental Educational and Behavioral Outcomes is an equal opportunity provider and encourages diversity in our associations. Shared Living Providers are independent contractors and not employees of the agency. Developmental Educational and Behavioral Outcomes makes all placement decisions without regard to an applicant’s race, religion, sex, age, national origin, sexual orientation, disability, or other protected classifications under federal, state, or local equal opportunity laws.

Date: (Required)

Date

Name:

First Name *

Last Name *

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Email Address: (Required)

Best Phone Number: (Required)

Work Phone Number:

Social Security Number:

Date of Birth:

Driver’s License State: (Required)

Driver’s License Number: (Required)

Referred By:

Ad
School
DEBO Employee
Shared Living Provider
Emp. Agency
Job Service
Radio
Job Fair
Other

Are you at least 18 years of age?

Are you authorized to work in the United States on an unrestricted basis?

Have you ever worked for Developmental Educational and Behavioral Outcomes?

If yes, specify the position and dates:

PLACEMENT DESIRED

Shared Living Home Location:

Date available: (Required)

Date available

Do you have an individual identified you would serve:

If yes, write the individual’s first name and last initial:

What interests you most about becoming an Shared Living Home Provider? (Required)

Are you currently a Shared Living home provider?

If yes, how long have you been contracted?

If you are or have been a Shared Living home sub-contractor, list the providing agency(s):

Do you own your home or rent/lease and are currently listed as a tenant on the leasing agreement?

Yes, Own
Yes, Rent

Please describe in detail how you plan to provide an adequate and appropriate residence for potential placement: (Required)

Placement Preferences:

Male
Female
Age under 18
Other age range

List any situations/conditions you are uncomfortable with/unable to work with: (Required)

Are pets present in the home?

If Yes, type:

Do residents of the home need to use stairs?

List all those who live with you at the potential placement residence : (Required)

First Name, Age, Relationship to Sub-contractor

QUALIFICATIONS

Do you have automobile insurance coverage?

Type: (Required)

Who is your current automobile insurance carrier? (Required)

Have you received three or more traffic violations in the last 3 years?

Has your driver’s license been suspended or revoked in the last 3 years?

Have you ever been convicted of a crime or are you subject to a pending criminal charge?

(No applicant will be denied solely on the grounds of a conviction or pending criminal charge. The nature of the offense, the date, the surrounding circumstances, and the relevance to placement will be considered.)

Explain all YES answers below:

EDUCATION

High School/GED:

Name of School: (Required)

Address: (Required)

Technical/Vocational:

Name of School:

Address:

Major:

College/University:

Name of School:

Address:

Major:

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Other

Name of School:

Address:

Major:

SPECIALIZED TRAINING, CERTIFICATION, OR EXPERIENCE

Training/Certification

Expiration Dates/Additional Comments:

Do you have experience in providing care or treatment for persons with any of the following:

Additional Comments:

List any license or certification you possess that is relevant to your application:

Are you able to speak a language other than English?

Language spoken:

WORK HISTORY

If you are currently employed, may we contact your employer?

Begin with current or most recent employer or position with employer:

(1) Employer: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Supervisor: (Required)

Phone Number: (Required)

Dates of Employment:

Start Date

–

End Date

Ending Wage: (Required)

Position: (Required)

Description of Job: (Required)

Reason for Leaving: (Required)

(2) Employer: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Supervisor: (Required)

Phone Number: (Required)

Dates of Employment:

Start Date

–

End Date

Ending Wage: (Required)

Position: (Required)

Description of Job: (Required)

Reason for Leaving: (Required)

(3) Employer: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Supervisor: (Required)

Phone Number: (Required)

Dates of Employment:

Start Date

–

End Date

Ending Wage: (Required)

Position: (Required)

Description of Job: (Required)

Reason for Leaving: (Required)

REFERENCES

Developmental Educational and Behavioral Outcomes requests that all applicants submit six (6) references, which may include: current or former contracting providers, employers, supervisors, teachers or others qualified to objectively evaluate your ability to provide the services for which you have applied. Please list the reference information identified below. Developmental Educational and Behavioral Outcomes reserves the right to contact some or all of your references.

Three Provider/Work References

(1) Employer: (Required)

Supervisor: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best phone number: (Required)

(2) Employer: (Required)

Supervisor: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best phone number: (Required)

(3) Employer: (Required)

Supervisor: (Required)

Address: (Required)

Best phone number: (Required)

Three Personal References

(1) Name: (Required)

Relationship to Applicant: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best phone number: (Required)

(2) Name: (Required)

Relationship to Applicant: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best phone number: (Required)

(3) Name: (Required)

Relationship to Applicant: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best phone number: (Required)

THANK YOU FOR YOUR INTEREST IN DEVELOPMENTAL EDUCATIONAL AND BEHAVIORAL OUTCOMES

We at Developmental Educational and Behavioral Outcomes are pleased you are interested in becoming a member of our Company. We are proud of our excellent reputation and the services we provide. We value diversity and want your experience with us to be enjoyable. Therefore, to help ensure a safe home environment and excellent services, we carefully screen the background of all applicants. This screening may include an oral interview, as well as an investigation of your work history, driving record, application information, and reference checks.

Developmental Educational and Behavioral Outcomes requires that an investigation of your background for any criminal conduct be completed upon prior to contracting and may be repeated randomly or as required by law thereafter. Some service areas may also require a screening for the use of illegal drugs.

APPLICANT DECLARATION OF UNDERSTANDING

I understand that Developmental Educational and Behavioral Outcomes may conduct an investigation of the information I have noted on this application and, as part of that investigation, may contact prior employers and references, among others. I authorize Developmental Educational and Behavioral Outcomes to conduct this investigation and I release from all liability and hold harmless any person giving or receiving information about me relative to this investigation.
I understand that any falsification, misrepresentation, or omission of information discovered as a result of this investigation may prevent my eligibility to contract or may subject me to the immediate termination of my contract with Developmental Educational and Behavioral Outcomes.
I understand that this application process does not create a contract.
I declare that I have never committed nor been charged or convicted of any act of abuse, neglect, exploitation, or fraud in relationship to a dependent/vulnerable child or adult within the past 10 years.
I declare that I have never knowingly violated any applicable rules or laws in any previous employment in a residential, healthcare, or similarly related employment.
I declare that the Office of Inspector General has never excluded me from participating in the Medicaid or Medicare programs.

By signing this application, I agree that I have read and understand the declarations listed above and I assert that all information given in this application is true.

Signature of Applicant

First Name *

Last Name *

Date (Required)

Date