Do you have a valid Driver's License? *
All Acquired Education - Check all that apply*
Name of HS or GED Institution?*
Name of College Educational Institution?*
Are you 18 years of age or older?*
Have you ever applied for employment with Kelsch Associates before?*
If you have applied for employment with Kelsch Associates before, list the date(s) below:*
Are you a previous employee of Kelsch Associates, Inc?*
Please list dates of prior employment with Kelsch Associates:*
Reason for leaving employment with Kelsch Associates*
Are you willing to work at ANY of our locations?*
Are you willing to attend Staff Meetings?*
Will you attend training sessions?*
Will you change Attends/Depends briefs on adults?*
Will you assist in transferring individuals?*
Will you work with individuals with challenging behaviors?*
Do you have current school obligations?
Name and Location of School*
Dates of Term (beginning and end)?*
Will you be receiving college credits?*
List school schedule below including days of week and class times:*
If hired, do you have other work obligations?*
If you have other work obligations:*
Are you interested in a Program Support Manager position?*
Are you interested in a Full Time (FT) Resident Program Worker position?*
Are you interested in a Part Time (PT) Resident Program Worker position?*
Are you interested in a Full Time FACT Activity Aide position?*
Are you interested in more than one shift/position?*
Current Employer Address*
Current Employer Phone Number*
Date of Hire for Current Employer
If you plan on leaving your current place of employment, please list reason(s) why and how much notice you will provide:*
Name of Previous Employer #1 (most recent)*
Address of Previous Employer #1*
Phone Number of Previous Employer #1
Dates of Employment Employer #1*
Reason for leaving Previous Employer #1*
Name of Previous Employer #2*
Address for Previous Employer #2*
Phone Number of Previous Employer #2*
Date of Employment for Previous Employer #2*
Reason for leaving Previous Employer #2*
Name of Previous Employer #3*
Address of Previous Employer #3*
Phone Number for Previous Employer #3*
Dates of Employment for Previous Employer #3
Reason for leaving Previous Employer #3*
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