Application

CCH INDIVIDUALIZED SUPPORT SERVICES

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CCH Individualized Support Services

EMPLOYMENT APPLICATION

* Indicates required field

Name *

First

Last

Are you interested in working out of our Port Townsend or our Port Angeles location? *

Port Angeles Port Townsend

What position would you like to apply for? *

Direct Support Staff Other

MAILING ADDRESS *

EMAIL ADDRESS *

Phone Number *

Referred by? *

When can you start? *

(

Pay desired? *

Are you currently employed? *

Can we contact your employer? *

Have you ever worked for this company before? *

Do you have a highschool deploma or GED? *

No Highschool Deploma GED

Please list your last four employers, dates of employment and telephone numbers *

In the case of an emergency, who would you like us to notify? Please list their name and telephone number *

What skills and abilities qualify you for this position? Why are you interested in working for CCH? *

Do you have any of the following? Please check all that apply *

Current CPR card CNA/RNA License HIV/AIDS education certificate Proof o TB test/Chest X-ray Fundamentals/Modified Fundamentals of Caregiving Certificate Continuing Education Certificate Nurse Delegation Certificate

Do you have a current Drivers License? *

Yes No

Would you be willing to obtain vehicle insurance limits of 100,000-300,000 for bolidy unjury. *

Yes No Already have

Do you have access to a reliable vehicle to transport clients on a regular basis? *

Yes No

Are you now, or do you expect to be, working in any other buisness or job? (Please explain) *

How did you hear about CCH? *

Submit

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Home
EMPLOYMENT
Meeting Your Needs
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