Team Application : Join Our Team : Developmental Education & Behavioral Outcomes

EMPLOYMENT APPLICATION

Developmental Educational and Behavioral Outcomes (DEBO) is an equal opportunity employer and encourages diversity in employment. DEBO makes all hiring 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)

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:

Place of Birth:

Driver’s License State: (Required)

Driver’s License Number: (Required)

Referred By:

Ad
School
DEBO Employee
Walk-in
Emp/Job Svc
Radio
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 before?

If yes, specify the position, company, and dates:

EMPLOYMENT DESIRED

Position: (Required)

Wages Desired: (Required)

Date available: (Required)

Hours preferred:

Part-time
Full-time

Days/Times available:

Are you willing to work overtime if necessary?

Are you willing to work in a home with pets?

QUALIFICATIONS

The use of illegal drugs is absolutely prohibited under Developmental Educational and Behavioral Outcomes policy. Where allowed by applicable law, Developmental Educational and Behavioral Outcomes may require employees to submit to drug testing as a condition of continued employment.

Do you possess a valid driver’s license?

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 employment 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 the position applied for 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:

Degree

College/University:

Name of School:

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Address:

Major:

Degree

Other

Name of School:

Address:

Major:

Degree

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:

Are you able to speak a language other than English?

Language spoken:

List any license or certification you possess that is relevant to the position you are applying for:

WORK HISTORY

Developmental Educational and Behavioral Outcomes bills Medicare for some of the services rendered. We must inform Medicare of any employee that has been employed by a Medicare Fiscal Intermediary during the past twelve months. If a Medicare Fiscal Intermediary has employed you in the past twelve months, please indicate the employer and the dates of employment.

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)

(4) Employer:

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Supervisor:

Phone Number:

Dates of Employment:

Start Date

–

End Date

Ending Wage:

Position:

Description of Job:

Reason for Leaving:

(5) Employer:

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Supervisor:

Phone Number:

Dates of Employment:

Start Date

–

End Date

Ending Wage

Position:

Description of Job:

Reason for Leaving:

REFERENCES

Developmental Educational and Behavioral Outcomes requests that all applicants submit six (6) references, which may include: current or former employers, supervisors, teachers or others qualified to objectively evaluate your ability to work in the position 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 Work References

(1) Employer: (Required)

Supervisor: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Day phone number: (Required)

(2) Employer: (Required)

Supervisor: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Day phone number: (Required)

(3) Employer:

Supervisor:

Address:

Day phone number:

Three Personal

(1) Name: (Required)

Relationship: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best phone number: (Required)

(2) Name: (Required)

Relationship: (Required)

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best phone number: (Required)

(3) Name: (Required)

Relationship: (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 work experiences to be enjoyable. Therefore, to help ensure a safe work 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 conditional hire 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 being hired or, if hired, may subject me to the immediate termination of my employment with Developmental Educational and Behavioral Outcomes.
I understand that this application process does not create an employment contract.
I understand all employment at Developmental Educational and Behavioral Outcomes is “at-will.” This means, if Developmental Educational and Behavioral Outcomes employs me, my employment is not for a specified or definite period of time and that I may resign or be discharged from my position at any time, for any reason, with or without cause or prior notice.
I understand that the “at-will” policy listed above cannot be changed or amended without a formal written employment agreement signed by me and by an officer of Developmental Educational and Behavioral Outcomes.
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