Employment Application Gatesway Foundation is an equal opportunity employer and does not discriminate against applicants and employees on the basis of race, sex, sexual orientation, color, religion, national origin, age, disability, genetic information, membership or application for membership in a uniformed service, status as a veteran or any other basis prohibited by federal, state or local law. Name* First Middle Last Date of Birth* MM slash DD slash YYYY Social Security #* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Preferred Phone*Alternative PhoneEmail* Position applying for:* CNA / DDCA CMA HTS HCC Other Other* How did you hear about this position at Gatesway?* Current Employee Internet Website Newspaper Ad Transitioning from other agency with consumer Walk-In Word of Mouth Have you ever applied for a job with Gatesway before?* Yes No If yes, when did you apply?* MM slash DD slash YYYY Have you ever been employed by Gatesway before?* Yes No If yes, when were you employed at Gatesway?* MM slash DD slash YYYY Are you interested in Full-Time or Part-Time work?* Full-Time Part-Time What hours and days are you available to work?* What date are you available to start work?* MM slash DD slash YYYY May we contact your current employer?* Yes No Are you authorized to work in the United States?* Yes No Do you have a valid Drivers License?* Yes (proof is required) No If yes, what state?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIf yes, provide Driver's License number, including any letters.*Have you ever been convicted of or pled guilty, nolo contendere or no contest to a criminal offense other than a minor traffic violation?* Yes No If yes, please explain.*Are there any pending criminal charges against you for an offense other than a minor traffic violation?* Yes No If yes, please explain.*Are you related to anyone employed by this agency?* Yes No If yes, please list to whom and also their relationship to you.* Educational BackgroundEducational Background*Check all that apply High School College Graduate School Other High School Name & Location* Did you graduate from high school?* Yes No College Name & Location* Course of study?* Did you earn your degree?* Yes No Graduate School Name & Location* Did you earn your graduate degree?* Yes No If other, please explain:*Employment ExperienceCompany name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Job Duties*Supervisor Name* Reason for leaving* Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Sign & DateHave you worked with people who have developmental disabilities?* Yes No Please mark any of the below training in which you are currently certified (proof is required):* Foundations ETL ETL2 PA1 PA2 Mealtime Challenges Residential Modules Other Certifications First Aid MAT CPR None Can you perform these essential job requirements either with or without reasonable accommodation?* Yes No I hereby certify that the facts stated in this application are true and correct to the best of my knowledge. I agree that any false or inaccurate information in this application is sufficient reason for Gatesway to refuse to hire me and, if hired, to terminate my employment. Gatesway is not obligated to provide me with employment and I am not obligated to accept employment. Nothing in this employment application or anything communicated to me during an interview is intended to create an employment contract between Gatesway and me. If I am employed by Gatesway, my employment will be at-will which means that either Gatesway or I may terminate the employment relationship at any time, for any lawful reason, with or without prior notice. Gatesway's employment-at-will policy may not be modified verbally by any person and may not be modified by a written statement appearing in a Gatesway policy or document other than a formal written employment agreement signed by Gatesway's Executive Director. If I am hired, I will be required to provide documentation of my identity and my employment eligibility in the United States in accordance with the Immigration Reform and Control Act of 1986. Illegal use, impairment, or sale of narcotic, or controlled substances (without a doctor’s prescription) or alcohol while on IOI property, at a remote worksite to which I am assigned to work, or while driving during the course of my employment is strictly prohibited. I agree to abide by the Alcohol and Drug Free workplace and testing policies of this company. Any violation of these standards may result in immediate termination of my employment. I authorize Gatesway to conduct a criminal background check and any other background check required as a condition of my employment by statute, regulation or other law or by a governmental agency. Signature (type full legal name here)* Date* MM slash DD slash YYYY Resume Upload Drop files here or Select files Max. file size: 300 MB.