Employment Application1 2 3 4 5 We understand your privacy concerns and will protect your information. Tell us about yourself. What’s your name and where do you live? How can we reach you?Name First Middle Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneCell PhoneEmail How did you hear about job openings?Our web siteOther internet sourceNewspaper adLangton Green staffStaff Member NameAre you related to or do you know a current or former Langton Green employee?NameRelationship Do you drive? Yes NoIs your license currently valid? Yes NoWhich state issued your license?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre you eligible to work in the United States? Yes NoAre you at least 19? Yes NoWhen can you start working? May we contact your current employer? Yes NoShift Availability Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7am-3pm Evening: 3-9pm Evening: 3-11pm Overnight: 10pm-8am Overnight: 11pm-9amWhat works for you? These shifts are our most common but can vary. Wages range from $9-11.50 per hour, depending on position and experience in the field of intellectual disabilities. Vacancies are subject to change.Would you be able to perform the essential functions of the positions chosen above, with or without reasonable accommodations? Yes No What High School did you graduate fromCity/StateWhenIf you don’t have a high school diploma, did you get your GED?WhereWhenDid you attend college?WhereWhenDegree What other education have you pursued? What skills have you developed? Now we’d like to hear about your work experiences. List as many as possible, and use the back of the sheet if needed. Start with your most recent employer, and work backwards from there.Work ExperienceNameSupervisorCity/StateDutiesPositionStart DateEnd DateWhy Left? Tell us your thoughts. Why is it important to you to work with intellectually and developmentally disabled adults?Are you involved? Do you volunteer in your community? What is the value of contributing to your community? What kind of volunteer activities have you participated in?In your own words, explain a Direct Care Professional’s role and importance to our agency.Are there past positions from which you were dismissed or asked to resign, or a position you resigned from to avoid being dismissed? If yes, explain: Yes NoYes, Past positions dismissed?ReferencesNameAddressPhone We’ll need at least three personal and/or professional references (but not family members). They should be people who have good insight into your skills, character, and abilities. Please provide, at the very least, a phone number and their first and last names. Initial 01Under Maryland law, it is a misdemeanor offense for any employer to require an employee to take a lie detector test as a condition of employment.Initial 02Langton Green, Inc. does not discriminate in hiring on the basis of color, religion, national origin, sex, age, marital status, pregnancy, sexual orientation, genetic information, disability, or any other characteristic protected by law.Initial 03I have read the statements of this application and also certify that the information presented herein is complete and accurate. I further understand that withholding information or presenting false information on this application or during an interview will constitute grounds for immediate rejection of the application, or withdrawal of offer of employment if made, or termination from employment if hired.Initial 04I hereby give Langton Green, Inc. permission to verify any and all references listed herein, and to obtain verification from previous employers of employment dates, reasons for separation, results of performance evaluations, and any other information relevant to verification of performance.Initial 05I hereby give Langton Green, Inc. permission to obtain criminal background and driving history reports after I have signed an offer of employment, and to be enrolled in Maryland Vehicle Administration driver history monitoring at any time after hire.Initial 06I hereby agree, when requested, to participate in drug and/or alcohol testing at a facility designated by Langton Green, Inc.SignatureI CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE STATEMENTS ABOVE AND THAT ALL INFORMATION PRESENTED IN THIS APPLICATION IS COMPLETE AND ACCURATE.