Shared Living Provider Application Step 1 of 7 - Contact Information 14% Name(Required) First Last Marital StatusSingleMarriedDivorcedWidowedSeparatedDomestic PartnershipAddress Street Address Address Line 2 City NebraskaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Enter Email Confirm Email Phone(Required)Social Security Number Occupation/Job Title(Required)Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherCurrent Work ScheduleJob DutiesMilitary History (please include branch and year(s) of service)/Type of Discharge Employeer #1Name of Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer's PhoneStart Date Month Day Year End Date Month Day Year Last Pay RateName of Supervisor Job Title Reason for Leaving Are you eligible for rehire? Yes No Job Duties were:Employeer #2Name of Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer's PhoneStart Date Month Day Year End Date Month Day Year Last Pay RateName of Supervisor Job Title Reason for Leaving Are you eligible for rehire? Yes No Job duties were: Education beyond high school:Do you have any special skills/job training that would be beneficial to being an SLP Provider? If so, please list and describe why you think they would be, and how they would benefit to your job duties as an EFH:Have you received any specialized training regarding individuals with development disabilities/intellectual functioning? If yes, please describe:Educational considerations: Do you currently have any children or other family members living with you? If yes, please list full name and age:Do you have any other children not living in the home? If yes, please list full name and age:Please describe the things your family does together:How would you incorporate your SLP into your family's every day life:Do you have any pets? If yes, please list name and breed:What kind of hobbies, special interests, groups, organizations, etc., do you actively participate in? PhoneDescribe the home layout (include floor plan, bedrooms, bathrooms, etc)Are there specific rules/regulation within your home that the individual would be required to follow? If yes, please describe in detail. This would include but is not limited to; smoking policy, having pets; chore responsibilities, drinking, relationships with peer, curfew, etc. Read thoroughly before signing – ask for clarification if there is something you don’t understand.I certify that the answers given in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this “Application for Employment” as may be necessary for arriving at an employment decision. I authorize any agent of VITAL Services Inc. to contact previous employers and my personal references for the purpose of verifying any information given in this application and for references regarding my character and work history. I further authorize any agent of VITAL Services Inc. to conduct a background check through one or more of the following: I also authorize any agent of VITAL Services Inc. to access and print my Motor Vehicle Record (MVR) from the internet – upon employment, and also anytime during employment with VITAL Services Inc., in order to satisfy the insurance carrier of my satisfactory driving records. This application for employment shall be considered active for a period of time not to exceed 60 days. (Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.) In the event of employment by VITAL Services Inc., I understand that: False or misleading information given in my application or interview(s) may result in discharge. I will be required to authorize downloading a current Motor Vehicle Record at my expense. I will be required to abide by all Policies and Procedures of VITAL Services Inc. I will be required to satisfactorily complete all required training within time allowed. I will be expected to stay informed of all current and revised rules, Policies and Procedures. I will be expected to get a drug test at NE Occupational Health before orientation or training will begin. Signature(Required) Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
