EMPLOYMENT APPLICATION
Please read each question carefully, using your tab key to navigate. Please do not leave any blanks.
 

APPLICANT INFORMATION

Last Name
First Name
M.I.
Today's Date *

MM 		/
DD 		/
YYYY
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
How did you hear about Bridges? *
Position Applying For *
Phone Number *

### 		-
### 		-
####
Email *
Interested in part-time or full-time hours? *
Drivers License # *
State of Issue *
Is your driver's license valid? *
 YES 
 NO 
Do you have current auto insurance? *
 YES 
 NO 
Do you have a reliable vehicle? *
 YES 
 NO 
Please note that the Direct and Community Support Specialist jobs often require an employee to use his/her own vehicle to transport consumers.
Have you had any moving violations in the last three years? *
 YES 
 NO 
Have you had any major violations in the last seven years? An example would be an at-fault accident. *
 YES 
 NO 
Are you willing to take a drug/alcohol test? *
 YES 
 NO 
Have you been found guilty of abuse or neglect on another person? *
 YES 
 NO 
Are you a citizen of the United States? *
 YES 
 NO 
If no, are you authorized to work in the U.S.?
 YES 
 NO 
Have you been convicted of a crime in the past seven years? *
 YES 
 NO 
If yes, explain in the lines below.
1st Incident
City/State
Charge
Do you have a good cause waiver?
 YES 
 NO 
2nd Incident
City/State
Charge
Do you have a good cause waiver?
 YES 
 NO 
Have you previously applied to Bridges? *
 YES 
 NO 
If yes, when?
Have you ever worked for Bridges? *
 YES 
 NO 
If yes, explain
 

EDUCATION

 
Registered in Family Care Safety Registry: *
 YES 
 NO 
If yes, date:

MM 		/
DD 		/
YYYY
CPR: *
 YES 
 NO 
If yes, date:

MM 		/
DD 		/
YYYY
Level 1 Medication Administration *
 YES 
 NO 
If yes, date:

MM 		/
DD 		/
YYYY
First Aid: *
 YES 
 NO 
If yes, date:

MM 		/
DD 		/
YYYY

Please list any other certificates, training, and credentials that may apply to the requirements of this position:
Do you have a high school diploma or equivalent?
 YES 
 NO 
College/Trade School
City
State
Did you graduate?
 YES 
 NO 
Degree
College/Trade School
City
State
Did you graduate?
 YES 
 NO 
Degree
 

PREVIOUS EMPLOYMENT

Please read each question carefully, using your tab key to navigate. Please do not leave any blanks.
 
Company
Phone Number

### 		-
### 		-
####
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Job Title
Name of Supervisor
Supervisor Job Title
From

MM 		/
DD 		/
YYYY
To

MM 		/
DD 		/
YYYY
Responsibilities
Reason for Leaving
Are you currently working for this employer?
 YES 
 NO 
May we contact this employer for reference?
 YES 
 NO 
Company
Phone Number

### 		-
### 		-
####
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Are you currently working for this employer?
 YES 
 NO 
From

MM 		/
DD 		/
YYYY
To

MM 		/
DD 		/
YYYY
Job Title
Name of Supervisor
Supervisor Job Title
Responsibilities
Reason for Leaving
Are you currently working for this employer?
 YES 
 NO 
May we contact this employer for reference?
 YES 
 NO 
Company
Phone Number

### 		-
### 		-
####
Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Are you currently working for this employer?
 YES 
 NO 
From

MM 		/
DD 		/
YYYY
To

MM 		/
DD 		/
YYYY
Job Title
Name of Supervisor
Supervisor Job Title
Responsibilities
Reason for Leaving
Are you currently working for this employer?
 YES 
 NO 
May we contact this employer for reference?
 YES 
 NO 
 

MILITARY SERVICE

 
Branch
From

MM 		/
DD 		/
YYYY
To

MM 		/
DD 		/
YYYY
Rank at Discharge
Type of Discharge
If other than honorable, explain
 

AVAILABILITY

Reasonable efforts will be made to accommodate sincerely held moral and ethical beliefs, religious beliefs, and practice.
Please list all times you are available
 
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Are you willing to work less than 8 hour shifts? *
 YES 
 NO 
Are you willing to work overnights? *
 YES 
 NO 
Are you willing to work in any area assigned, including the city, county, and/or St. Charles County? *
 YES 
 NO 
Are you willing to work double shifts? *
 YES 
 NO 
 

REFERENCES

Please list professional references. Do not include relatives or name supervisors listed above.
 
Full Name *
Relationship *
Years known *
Company Name *
Phone Number *

### 		-
### 		-
####
Email *
Full Name *
Relationship *
Years known *
Company Name *
Phone Number

### 		-
### 		-
####
Email *
Full Name *
Relationship *
Years known *
Company Name *
Phone Number *

### 		-
### 		-
####
Email *
 

RELEASE AND SIGNATURE

 

APPLICANT NOTE
This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract or guarantee
of an interview. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview
and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All
qualified applicants will receive consideration without discrimination based on sex, marital status, race, color, age, creed, national origin,
sexual orientation, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness,
deafness or physical handicap, or the presence of disabilities. A conviction will not necessarily bar an application from employment.
Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment.

CERTIFICATION AND RELEASE
I certify that I have read and understand the applicant note on this form and that the answers given by me to the forgoing questions and
statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions
or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or
discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify
any of this information. I release all former employers, persons, schools, companies and law enforcement authorities from any liability for
any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If
company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

RELEASE TO PREVIOUS EMPLOYERS
I, the undersigned, have applied for employment with Bridges Community Support Services and authorize previous employer(s) to verify
employment data and to provide information concerning past performance under the provisions of the Privacy Act of 1974. All information
is kept confidential. I hereby authorize to issue any information you may have regarding my services and character and do hereby
unconditionally release your organization from all liability for any damage whatsoever which might result from furnishing same.
DIGITALLY SIGNED BY APPLICANT* *
*Typing name constitutes a signature by applicant.
Todays Date *

MM 		/
DD 		/
YYYY

Your application will be kept for one year.
Bridges Community Support Services is an at-will employer.
Bridges Community Support Services is an equal opportunity employer.
Bridges Community Support Services will make every attempt at reasonable accommodation for employees of all abilities.
Bridges Community Support Services is required to adhere to FMLA guidelines outlined by WHD Publication 1420.
Should your qualifications fit the needs of the position, Bridges will make every effort to contact you within 10 business days of your application submission.
----------------------------------------------------------------------

The following is an optional form on this application and has absolutely no bearing on your employment opportunities. If you would like to voluntarily submit this information, please complete the form and digitally sign. Otherwise, please leave blank.

 
 

BRIDGES COMMUNITY SUPPORT SERVICES EQUAL EMPLOYMENT OPPORTUNITY REPORTING CONFIDENTIAL DATAREQUEST FORM

 
 

Bridges Community Support Services is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation or any other classification protected by Federal, state, or local law. The information requested in this form will be used only in the compilation of data for Equal Employment Opportunity Commission reporting. Completion of the requested data will not affect any terms or conditions of employment.

Your Information

Name:
Position Title:

Gender Information

Please mark appropriate response.
 Male 
 Female 

Ethnicity Information

Please mark one description corresponding to the ethnic group with which you most identify.
 AMERICAN INDIAN or ALASKAN NATIVE (not of Hispanic origin)  
 NATIVE HAWAIIAN OR PACIFIC ISLANDER (not of Hispanic origin) 
 ASIAN (not of Hispanic origin) 
 BLACK OR AFRICAN AMERICAN (not of Hispanic origin)  
 HISPANIC OR LATINO 
 WHITE (not of Hispanic origin)  
 TWO OR MORE RACES (not Hispanic or Latino)  
AMERICAN INDIAN or ALASKAN NATIVE (not of Hispanic origin) All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.

NATIVE HAWAIIAN or PACIFIC ISLANDER A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

ASIAN A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

BLACK (not of Hispanic origin)
All persons having origins in any of the black racial groups of Africa.

HISPANIC
All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish
culture or origin.

WHITE (not of Hispanic origin)
All persons having origins in any of the original peoples of Europe, the Middle East, or North
Africa.

TWO OR MORE RACES (not Hispanic or Latino)
All persons who identify with more than one of the above races.
Digitally signed by Applicant* *
*Typing name constitutes a signature by applicant.
Today's Date

MM 		/
DD 		/
YYYY
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