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CLS/Respite position

*Please note, this CLS/Respite positions will not be employed directly by GCCMH. They are employed by the consumer to provide the services.

Employment Application - CLS/Respite position

*Please note, this CLS/Respite positions will not be employed directly by GCCMH. They are employed by the consumer to provide the services.

Position for which you are applying:
Name
First Middle Last
Address City State ZIP Code
Phone Number
Email
Are you at least 18yrs of age or older?*
- Yes
- No
Are you eligible to work in the U.S.?*
- Yes
- No
Can you work any shift?
- Yes
- No
Can you work overtime, including weekends?
- Yes
- No
Do you have a valid driver's license?
Are you capable of performing with or without reasonable accommodation (special assistance, equipment or other help), the activities involved in the job or occupation for which you have applied?
If accommodations are needed, please explain
Accommodation Description
Education
Name and Location of School - 1
Degree/Diploma Received - 1
Number of Years Attended? - 1
Please enter a number from 0 to 10.
Did you graduate? - 1
- Yes
- No
Education (cont)
Name and Location of School - 2
Degree/Diploma Received - 2
Number of Years Attended? - 2
Please enter a number from 0 to 10.
Did you graduate? - 2
- Yes
- No
Education (cont)
Name and Location of School - 3
Degree/Diploma Received - 3
Number of Years Attended? - 3
Please enter a number from 0 to 10.
Did you graduate? - 3
- Yes
- No
Education (cont)
Name and Location of School - 4
Degree/Diploma Received - 4
Number of Years Attended? - 4
Please enter a number from 0 to 10.
Did you graduate? - 4
- Yes
- No
Employment History
How many employers have you have in the last five (5) years?
Current Employer's Name
Dates:
month and year
Address
Address City State ZIP Code
Phone
Supervisor (Name and Title)
Your Title:
Duties and Responsibilities:
Reason for leaving:
Former Employer 1
Former Employer's Name
Dates:
month and year
Address City State ZIP Code
Supervisor (Name and Title)
Your Title:
Duties and Responsibilities:
Reason for leaving:
Former Employer 2
Former Employer's Name
Dates:
month and year
Address City State ZIP Code
Supervisor (Name and Title)
Your Title:
Duties and Responsibilities:
Reason for leaving:
Former Employer 3
Former Employer's Name
Dates:
month and year
Address City State ZIP Code
Supervisor (Name and Title)
Your Title:
Duties and Responsibilities:
Reason for leaving:
If Yes, State, #:, and Exp. Date
Professional/Work References:
Please include at least 2 professional references
Name - 1
First Last
Address City State ZIP Code
Phone
Name - 2
First Last
Address City State ZIP Code
Phone
Name - 3
First Last
Address City State ZIP Code
Phone
Additional Information
Please provide any additional information or comments that may be relevant for the position.
How did you learn about this job posting
- Facebook
- CMH website
- Online Job Posting
- Newspaper
Please wait for the confirmation message after submitting your application before leaving the page.

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