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On-line Employment Application Step 1 of 4 25% Name* First Middle Last Email:* Street or Mailing Address:* City, State and Zip Code* Phone:* Alternate Phone: Desired Position* Direct Support Staff Management/Coordinator Other Days Available for Work* Sunday Monday Tuesday Wednesday Thursday Friday Saturday I will Accept* Full-time (40 hours per week) Part-time Substitute/On-call/As needed Hours Available* 1st Shift (after 7am) 2nd Shift (after 2pm) 3rd Shift (after 11pm) Wake 3rd Shift (after 11pm) Sleep (paid at minimum wage) Specific requirements or limitations to days/hours available:Geographic Areas you are willing to accept work in:* Hartford West Hartford Newington Wethersfield Manchester East Hartford Meriden Wallingford Cromwell Middletown Cheshire Danbury Berlin Greater Waterbury Area Ansonia Seymour Shelton Hamden Referral Information:* American Job Bank (Ct Dept of Labor) RMS Website On-line Employment Service Friend/Relative working for RMS Indeed.com If referred by on-line employment service, which one? If referred by friend/relative working for RMS, please provide name so current RMS employee can receive referral incentive: Have you graduated from HIgh School or acquired a G.E.D.?* Yes No When applying for a management or higher position, attach a list of any additional years of education, any degree(s) earned and institution(s) attended with address(es).Are you currently certified in CPR and First Aid? Yes No If no, to become certified in CPR you must be able to demonstrate chest compressions and rescue breaths on the floor for 2-5 minutes. Do you have any physical limitations that would prevent you from becoming certified? Yes No Are you currently certified in P.M.T. (Physical/Psychological Management Techniques? Yes No Are you currently Certified by the State of CT through DDS to Administer Medications? Yes No If no, do you have a history of being Certified by the State of CT through DDS to Administer Medications? Yes No If not currently Certified by the State of CT through DDS to Administer Medications, have you taken the initial med cert exam in the past? Yes No If not currently certified by the State of CT through DDS to Administer Medications, how many times have you passed the med cert exam? If not currently certified by the State of CT through DDS to Administer Medications, how many times have you failed the med cert exam? If yes, list certification number: If yes, expiration date on Med Cert card: Other Relevant Education/Training (relative to the position for which you are applying):Include certification types, numbers, and expiration dates where applicable. Are you 18 years or older?* Yes No Do you have a valid Driver's License?* Yes No Driver's License Operator #:* State:* Do you communicate in another language?* Yes No Language: Can you, after employment, submit verification of your legal right to work in the U.S.?* Yes No Do you have any substantiated allegations against you regarding the abuse, neglect, or mistreatment of a person with a developmental/intellectual disability in CT or any other state?* Yes No If yes, explain:If yes, are you listed on the CT DDS Registry? Yes No The DDS Registry is a centralized database regarding substantiated abuse or neglect. Have you ever worked for RMS before?* Yes No If yes, where? If yes, when? If yes, reason for leaving: Former EmployersName of Current or Last Employer: Full Address: Description of Work: Job Title: Starting Date: Leaving Date: Reason for Leaving: Name of Supervisor: May we contact her/him? Yes No Phone: Best time to call: Name of Employer: Full Address: Description of Work: Start Date: Job Title: Leaving Date: Reason for leaving: Name of Supervisor: May we contact her/him? Yes No Phone: Best time to call: Name of Employer: Full Address: Description of work: Start Date: Job Title: Leaving Date: Reason for Leaving: Name of Supervisor: Other Relevant Work or Volunteer Experience with adults with intellectual/developmental disabilities:AUTHORIZATIONS* I agree with the statements in the following AUTHORIZATIONS: I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application will be grounds for dismissal. I authorize the investigation of all statements contained herein. I also authorize all the references and employers listed on this application to give Residential Management Services, Inc. (hereafter referred to as RMS, Inc.) any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise. I release all parties from all liability for damages that may result from furnishing RMS, Inc. the same. I understand that as a condition of employment I must have and maintain a valid CT state Driver's License and that a poor driving record will result in my not being accepted for any position. I hereby authorize RMS, Inc. to secure information regarding my driving record from the CT state Department of Motor Vehicles through whatever agents they may choose. I understand the RMS, Inc. will have a Police Record and CT DDS Registry Check Done on all applicants. I also understand that authorizations for these checks are a condition to initial and continued employment with RMS, Inc. I authorize RMS, Inc. to secure information on felony and misdemeanor convictions and the DDS Registry through whatever agents they may choose. I understand that certain convictions may result in my not being accepted for any position. I further understand that being listed on the CT DDS Registry will result in my not being accepted for any position. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice. My name and date below serve as my electronic signature. Name First Last Date MM slash DD slash YYYY How do you think society perceives individuals with developmental disabilities?*Imagine that you go to the mall with three individuals that you support. One begins swearing loudly and hitting himself in the head. The other individuals begin to get upset and you see that people are looking at you and the individuals. Explain how you would handle the situation. If you decide to leave, what if the individual refuses to leave the mall?*NumberNumber