Job Application

Complete all 6 pages of the application below.

Personal Information

Name: *
SSN#:
E-mail: *
Address: *
Home Phone: *
-
Mobile Phone:
-
Are you entitled to work in the United States? *
Are you 21 or older? *
Military Service: *
      Branch:
Are you a veteran? *
      War:
What Position are you applying for? *
How did you hear about this position? *
Expected Hourly Rate:
Date Available: *
 /  / 
Have you ever applied to Stepping Stones before? *
      When?

Prior Work Experience

Current or Most Recent

Employer 1:
Employer 1 Address:
Employer 1 Phone:
-
Employer 1 Name of Immediate Supervisor:
Employer 1 Position / Job Title:
Employer 1 Start Date:
Employer 1 End Date:
Employer 1 Pay:
Employer 1 Reason for Leaving:
May we contact Employer 1?

Prior

Employer 2:
Employer 2 Address:
Employer 2 Phone:
-
Employer 2 Name of Immediate Supervisor:
Employer 2 Position / Job Title:
Employer 2 Start Date:
Employer 2 End Date:
Employer 2 Pay:
Employer 2 Reason for Leaving:

Prior

Employer 3:
Employer 3 Address:
Employer 3 Phone:
-
Employer 3 Name of Immediate Supervisor:
Employer 3 Position / Job Title:
Employer 3 Start Date:
Employer 3 End Date:
Employer 3 Pay:
Employer 3 Reason for Leaving:
May we contact Employer 3?

Education

High School

High School Name/Location:
High School Last Year Complete:

College/University

College/University Name/Location:
College/University Last Year Complete:
College/University Degree:
College/University Major or Emphasis:

Trade School/Certification

Trade School/Certification Name/Location:
Trade School/Certification Degree/Certification:

Other

Other Name/Location:
Other Degree:
List any applicable special skills, training or proficiencies:

Personal References

Reference 1

Reference 1 Name:
Reference 1 Address:
Reference 1 Phone:
-

Reference 2

Reference 2 Name:
Reference 2 Address:
Reference 2 Phone:
-

Reference 3

Reference 3 Name:
Reference 3 Address:
Reference 3 Phone:
-

Questions

Please answer the following questions as part of the interview process.

What is your goal (or reason_ for wanting to work with people who have mental illness?
Briefly list the experiences you have had that helped develop your interest in working with people:
How should you respond if someone refused to cooperate with what is considered a reasonable request?
What would you do if someone threatened to hit you? Another person?
What would you do if a person began to speak in a bizarre manner?
What would you do if a person said they were hearing voices that told them to do bad things?

Driving Abilities

Personal Information

Name on Driver's License:
Driver's License Number:
Date Issued:
 /  / 
Expiration Date:
 /  / 
Restrictions:
In the last three years have your driving privileges ever been suspended or revoked? *
Have you been convicted of more than two moving violations in the past three years? *
Have you been convicted of a DUI/DWI in the past two years? *
Have you been found at fault for a fatal accident within the past 5 years? *
Have you been convicted of leaving the scene of an accident within the past 3 years? *
Have you been convicted of reckless driving within the past 12 months? *
Have you ever been or are you subject to seizures? *
Are you medically cleared to drive? *
Do you have any physical defects which may cause dizziness or loss of consciousness? *
Will you report, in writing to the HR manager, ANY changes in the above information? *

Note: Stepping Stones reserves the right to verify your driving record as a condition of employment.

Note: Any tickets you incur while driving company vehicles are your responsibility.

Any falsification and/or unreported changes in the above information may result in revocation of driving privileges and possible suspension or dismissal from employment.

Eligibility for hire is dependent upon passing a criminal background check.

I hereby certify that the information I have entered on this application, to the best of my knowledge, is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired. I also provide consent for former employers to be contacted regarding work records. *