Career Inquiry Form
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Email Address
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Phone
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Position Applied for
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Direct Care Staff (Home Care)
RN/LPN (Home Care)
Cafe Team Member
Residential Care (Direct Care)
Habilitation Care (Direct Care & Support)
RN/LPN
Administrative
Date Available
*
MM
/
DD
/
YYYY
Location Preference
*
Hartville
West Lafayette
Home Health Services (Stark/Summit/Portage Areas)
Desired Weekly Salary
$
Dollars
.
Cents
Are you 18 years of age or older?
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Yes
No
Do you have a valid Ohio driver's license?
*
Yes
No
Are you a citizen of the United States?
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Yes
No
Work Visa/Green Card
Have you worked for GentleBrook or any of our affiliate locations?
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Yes
No
Have you ever been bonded?
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Yes
No
Are you interested in Full-time or Part-time work?
*
Full-time
Part-time
What hours can you work?
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Days
Afternoons/Evenings
Nights
Will you work overtime if asked?
*
Yes
No
Have you ever been convicted of a felony or misdemeanor?
*
Yes
No
High School Name & Address
Course of Study
Education
High School Graduate or Equivalent
Currently Enrolled in Trade or Vocational School
Trade or Vocational Degree
Some College
Associate Degree
Bachelor's Degree
Graduate of Professional Degree
If Applicable Name of College/Technical School
If Applicable College/Technical School Field of Study
Personal Reference #1
Name
First
Last
Personal Reference #1
Telephone Number
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Personal Reference #1
How do you know this person?
Personal Reference #2
Name
First
Last
Personal Reference #2
Telephone Number
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Personal Reference #2
How do you know this person?
Employment History #1
Company Name
Company Address
Street Address
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State / Province / Region
Postal / Zip Code
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United Kingdom
Australia
Canada
France
New Zealand
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Brazil
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Afghanistan
Åland Islands
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Angola
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British Indian Ocean Territory
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Bulgaria
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Chile
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Finland
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Gambia
Georgia
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Grenada
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Guinea-Bissau
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Hungary
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Indonesia
Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jordan
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Kenya
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Latvia
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Lesotho
Liberia
Libya
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Malaysia
Maldives
Mali
Malta
Marshall Islands
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Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
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Myanmar
Namibia
Nauru
Nepal
Netherlands
Curacao
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
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Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
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Spain
Sri Lanka
Sudan
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Sweden
Switzerland
Syria
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Tajikistan
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Tonga
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Uruguay
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Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Supervisor's Name
First
Last
Contact Telephone Number
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Job Title & Work Description
Employed From:
MM
/
DD
/
YYYY
Employed To:
MM
/
DD
/
YYYY
Weekly Pay
$
Dollars
.
Cents
Reason for Leaving
Employment History #2
Company Name
Company Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
----
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Democratic Republic of the Congo
Republic of the Congo
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Curacao
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Supervisor's Name
First
Last
Contact Telephone Number
###
-
###
-
####
Job Title & Work Description
Employed From:
MM
/
DD
/
YYYY
Employed To:
MM
/
DD
/
YYYY
Weekly Pay
$
Dollars
.
Cents
Reason for Leaving
Attach a Copy of Your Resume
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Comments/Additional Information
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteral status, or any other legally protected status.
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