Name *

Name

First Name

Last Name

Email Address *

Phone *

Phone

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you 18 years of age or older? *

Yes

If no, please state your age

Date of Last Physical Exam

YYYY

Date of Last TB Test

YYYY

Have you ever been employed under a different name? *

Yes

If Yes, Please list all names used

Do you possess a California Driver's License? *

Yes

California Driver's License Number

Has your Driver's License ever been suspended or revoked? *

Yes

If yes, please explain

Previous Employment (List most recent experience first. Number each Employer)

Name & Address of Employer, Telephone #, Job Title and Type of Work, Reason for Leaving, and Date Range

Please explain in detail any gaps in your employment history

Have you ever been involuntarily terminated or requested to resign? *

Does not include layoffs

Yes

Select Highest year of Education Grade Completed *

Diploma / GED? *

Yes

Currently Enrolled in High School Completion Course?

Yes

If yes, give expected completion date

YYYY

Education

Course Title, School or Organization Name and Address, # Units Completed, Date Completed, Currently Enrolled

Higher Education

University College or Business School Name and Address, Major Subject, # of years completed, # of units completed, Diploma degree or certificate, Date Completed.

How were you referred to our company? *

Referral Name

Employee name, advertisement location, agency name, or other

List Licenses or Certificates of Competetence Held

Names of Professional Associations of which you are a member

Have you been convicted of a crime within the last seven years? *

Do not include convictions that have been expunged or sealed.

Yes

If yes, state nature of crime(s), when and where convicted, and disposition of case. A criminal conviction may not always preclude you from employment. Surrounding circumstances and the relevance of the offense to job you are applying to may be considered.

Do you have a DSP I Certificate *

Yes

Do you have a DSP II Certificate? *

Yes

If yes, where did you receive your DSP I and/or DSP II Certificate?

Are you CPI Certified? *

Yes

Are you CPR/First-Aid Certified? *

Yes

Do you have your Adult Residential Facilities (ARF) Administrator's Certificate? *

Select 'Yes' only if ARF Administrator's Certificate is current.

Yes

Do you have your Regional Service Orientation (RSO) Certification? *

Yes

Do you have friends or relatives working for MDH Network?

If yes, list name and relationship of friend or relative working at the MDH Network

Jane, an individual from the program is not participating in an activity and ignores your requests to join. What would you do to encourage Jane to participate? *

Describe a specific situation where you have helped build enthusiasm in others in your most recent position. Why was this effective? *

Describe a situation at your work site when you went over and beyond what was expected of you. *

Why would you like to join the MDH Network team? *

Date available to start at the MDH Network *

Date available to start at the MDH Network

YYYY

Do you have a pre-planned vacation scheduled within the next 60 days? *

Please list scheduled date and number of days.

By clicking the 'SUBMIT APPLICATION' button above, I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification.

Direct Support Professional II (DSP I&II) Application

MDH Network

Direct Support Professional II (DSP I&II) Application