DIVINE WISDOM INTERVENTION, LLCEMPLOYMENT APPLICATION Personal Information Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone No. * (###) ### #### Secondary Phone No. * (###) ### #### Email * Driver License Number * Social Security Number * Have you ever been convicted of a crime? Yes No If Yes, please explain nature of offense(s), dates, sentence(s), rehabilitation, etc: Employment Desired Position Applying For Peer Support Specialist QP Community Outreach Date Available to Start: MM DD YYYY Desired Pay * * Per Hour Salary Employment Desired * Full-Time Part-Time Hours Per Week Available * Referred By: * (if applicable) Do you have Peer Support experience? Yes No If yes, how many years of experience? Do you have a Peer Support Certification? * Yes No Date of last Peer Support Certification * MM DD YYYY Applicable Certifications The following certifications are require for Peer support. Indicate if certified and the date of the certification. Please provide copies where indicated. WRAP Certification? * Yes No Date of Certification * MM DD YYYY CPR Certification? * Yes No Date of last CPR Certification * MM DD YYYY First Aid Certification? * Yes No Date of last First Aid Certification * MM DD YYYY Blood Borne Pathogens Certification? * Yes No Date of last Blood Borne Pathogens Certification * MM DD YYYY NCI/EDPI Certification? * Yes No Date of last NCI/EDPI Certification * MM DD YYYY Employment (list most recent first) Employer * Position * Reason for Leaving * Start Date * MM DD YYYY End Date * MM DD YYYY Currently Employed Here? * Yes No Hourly Pay Rate * Company Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisors Name * First Name Last Name Contact Information * (Phone Number or Email) Employer * Position * Reason for Leaving * Start Date * MM DD YYYY End Date * MM DD YYYY Currently Employed Here? * Yes No Hourly Pay Rate * Company Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisors Name * First Name Last Name Contact Information * (Phone Number or Email) Employer * Position * Reason for Leaving * Start Date * MM DD YYYY End Date * MM DD YYYY Currently Employed Here? * Yes No Hourly Pay Rate * Company Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Supervisors Name * First Name Last Name Contact Information * (Phone Number or Email) Preferred Counties to Work * List all counties within the state of North Carolina that you would prefer to work in below Education History GED City and State (ex: Raleigh, North Carolina) Graduated Yes No High School City and State (ex: Raleigh, North Carolina) Graduated Yes No Graduate School * City and State (ex: Raleigh, North Carolina) Graduated Yes No Trade School City and State (ex: Raleigh, North Carolina) Graduated Yes No Professional References Reference #1 * First Name Last Name Company & Position * Contact Information * (phone number or email) Reference #2 * First Name Last Name Company & Position * Contact Information * (phone number or email) Reference #3 * First Name Last Name Company & Position * Contact Information * (phone number or email) Line I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should this application contain any false or misleading information, my application may be rejected or my employment with this company terminated. * First & Last Name Date * MM DD YYYY At Will Employment Policy Divine Wisdom Intervention, LLC is an at will employer, and may terminate this relationship at any time, for any reason, with or without cause or notice. Please understand that no supervisor, manager, or other representative of Divine Wisdom Intervention, LLC, other than the Owner, and/or Human Resources Coordinator has the authority to enter into any agreement with you for employment for any specified period. Further any employment agreement entered into by the Owner is not enforceable unless in writing. You should also understand that the employment procedures, pratices, policies, and benefits outlined by by Divine Wisdome Intervention, LLC or described in any handbook may be modified or discontinued at any time. As an employee, you will be informed as changes occur. * First & Last Name Date * MM DD YYYY Thank you for your submission. We will review your application and reach out to you if you are selected for the next steps.
