Please provide the following contact information:

First Name:

Last Name:

Middle Init:

Date:

SSN#:       Date of Birth:

DL#:   State: AL AK AR AZ CA CO CN DE FL GA HI ID IL IN IA KS KY LA ME MD MS MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Expires:

Street Address:  City:  State:    Zip:   Country: County:

Home Phone:

Work Phone:

E-mail:

Position Desired? HTS PM Companion Community Employment Finance Support

Have you ever been employed with Bios?:  No Yes

If Yes, Date:  Location: Sapulpa Tulsa Muskogee Bartlesville OKC

Area Preference:     Sapulpa Tulsa Muskogee Bartlesville Oklahoma City

Are you legally eligible for work in the United States?     Yes No

Pay Expected:

Date available to begin work?

VOLUNTARY INFORMATION

Race: White Black Amercian Indian Asian Hispanic Other

Sex:  Male Female

# of Dependents: 1 2 3 4 5 6 >6

Are You a Veteran?   No Yes

If Yes, which Branch? NA Army Navy Air Force Marines Reserves

List any relatives or friends employed by our Agency:         Marital Status: Single Married Divorced Widowed

EDUCATION

High School:   Graduated? No Yes        Technical/Trade: Graduated? No Yes

College: Course of Study: Graduated? No Yes   If No, Years completed? NA 1 2 3

Bios requires that a criminal history check be provided by you prior to employment. Contract Standards require that this report not have any felonies or misdemeanor convictions such as an previous DUI, robbery, child abuse, etc.. Also, at any time during your employment, you may be subject to drug screening.    Have you ever been convicted of a felonious crime or misdemeanor?  No Yes

Do you have any Abuse, Neglect or Exploitation investigations pending against you with DMRS, DHS, OCA or APS?   Yes   No

Have you worked in the area of Direct Care? No Yes    Have you worked with developmentally disabled individuals? No Yes

What Direct Care training do you have? Foundations CPR First Aide MAT ETL RES MODS Special Skills or Training:

Special Licenses: (Include Lic. # & States currently licensed)

This job may require the following: Reliable Transportation  Yes No         Home Phone: Yes No        Lifting at least 50lbs: Yes  No

Do you have a valid Driver's License?YesNo   Valid Auto Insurance?Yes No  Understanding this, are you eligible for hire? Yes No

REFERENCES

List 5 Personal References:

Name: Name:  Name: Name: Name:

Phone:       Phone:         Phone:         Phone:          Phone:

Why do you want to work for Bios?

Bios is a community-base provider agency contracted with the State department that serves people with Developmental Disabilities. We do not discriminate in any way regarding race, sex, religion, age, disability or creed.

EMPLOYMENT

Company:

Company:

Company:

Address:

Address:

Address:

Employed from: to:

Employed from: to:

Employed from: to:

Supervisor Name:

Supervisor Name:

Supervisor Name:

Job Title/Description:

Job Title/Description

Job Title/Description:

Reason for Leaving?

Reason for Leaving?

Reason for Leaving?

To process your application, please bring your driver's license, current auto insurance and social security card.   The information provided in this Application for Employment is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.