Employment Application

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Employment Application

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Application Date*

MM slash DD slash YYYY

Position applying for:*

Department:

Personal Information

Name*

First Middle Last

Present Address*

Street Address City Region ZIP Code

Home Phone*

Mobile Phone

Email*

If hired, when can you begin employment with Cordia?*

MM slash DD slash YYYY

Are you at least 18 years old?*

Yes

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Birth date

MM slash DD slash YYYY

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Cordia work history

Have you ever worked for Cordia previously?

Yes

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Please provide job title, department, and dates of employment:

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Are you legally authorized to work in the United States?*

Yes

Are you willing to work with individuals who may display challenging behaviors?*

Yes

Are you able to provide physical assistance to individuals as needed?*

Yes

Are you able to bend, kneel, lift (up to 25 pounds), stoop, stand and/or sit for long periods of time, work in a community environment, handle wheelchair requirements (if needed), with our without reasonable accommodation?*

Yes

Educational History

Are you a high school graduate?*

Yes

High school name & city, state location:

Street Address Address Line 2 City Region

School(s) beyond high school (please list names and locations of the schools):

Graduated?

Yes

Degree(s)/Certificate(s) Earned:

Record of Employment (last 10 years)

Cordia will confirm dates of employment, positions held, reasons for leaving with prior employers. Explain ALL gaps in employment and other information relevant to eligibility, qualification, and suitability with prior employers in the “Additional Information” section.

Name of present or last employer:*

Employer address

Street Address City Region

Full time or Part time?*

Full time

Part time

Type of business*

Name of supervisor*

Phone*

Start date*

MM slash DD slash YYYY

End date*

MM slash DD slash YYYY

Your job title*

Starting pay*

Ending pay*

Reason for leaving*

Description of work and responsibilities*

Add 2nd employer?

Yes

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Previous Employer

Name of employer

Employer address

Street Address City Region

Full time or Part time?

Full time

Part time

Type of business

Name of supervisor

Phone

Start date

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Your job title

Starting pay

Ending pay

Reason for leaving

Description of work and responsibilities

Add 3rd employer?

Yes

This field is hidden when viewing the form

Previous Employer

Name of employer:

Employer address

Street Address City Region

Full time or Part time?

Full time

Part time

Type of business

Name of supervisor

Phone

Start date

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Your job title

Starting pay

Ending pay

Reason for leaving

Description of work and responsibilities

Add 4th employer?

Yes

This field is hidden when viewing the form

Previous Employer

Name of employer:

Employer address

Street Address City Region

Full time or Part time?

Full time

Part time

Type of business

Name of supervisor

Phone

Start date

MM slash DD slash YYYY

End date

MM slash DD slash YYYY

Your job title

Starting pay

Ending pay

Reason for leaving

Description of work and responsibilities

Add more employers?

Yes

This field is hidden when viewing the form

More Employers

Add additional employers, dates worked and description of duties

Upload Resume

Accepted file types: doc, pdf, Max. file size: 512 MB.

I understand that, if accepted for employment, I shall be required to provide proof of identity and eligibility to work in the United States (in compliance with the Immigration Reform & Control Act of 1986), as a condition of employment. In connection with this application, I authorize all corporations, companies, credit agencies, education institutions, persons, law enforcement agencies, military services, and former employers to release information that they may have about me to Cordia or its agents and release them from any liability for doing so. Also, I understand that a medical exam, pre-employment drug testing and/or criminal/abuse/neglect checks may be performed and that any offer of employment and continued employment is contingent upon receipt of satisfactory clearance.

I understand that this application does not, by itself, create a contract of employment. I also understand that an acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I further understand and agree that, if accepted for employment by Cordia or its subsidiaries, I will have no expectation of privacy in the property owned by the organization.

I understand that if employed, I have been hired at the will of my employer and that my employment may be terminated at any time, with or without cause and with or without notice.

Confirmation of Accuracy*

I understand that any misleading or incorrect statements may render this application void. I agree the company is not liable in any response if my employment is terminated because of false statements, answers, or omissions by me in the application.

I agree.