Online Employment Application

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Resource, Support, & Development, Inc.

RSD, Inc.
2110 Overland Avenue Suite 126
PO Box 80185
Billings, MT 59108-0185
Ph (406)652-5443 / Fax (406)652-9361

Direct Care Staff Application for Employment

Personal Information:

Full Name

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Street AddressEnter your mailing address

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City

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State

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Postal Code

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Are you 18 years of age or older?The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 year of age.

YesNo

Phone Number

Employment Desired:

Program/Position

Date you can start

Are you currently employed?

YesNo

If yes, can we contact your present employer?

YesNo

Current or Last Employer's Name

Phone Number

Current or Last Employer's Full AddressStreet, City, State, Postal Code

Are you related to anyone currently employed at RSD, Inc?

YesNo

If yes, what is their full name?

How did you hear about RSD, Inc?If you were referred, please provide their name.

General Information:

List your place of residence for the past seven years starting with your current physical address.One address per line.

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Have you been convicted of a felony or misdemeanor within the last five (5) years?You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied

YesNo

Do you have a current Montana Driver's License?

YesNo

Date of Birth

Current Driver's License Number:

Driver's License Expiration Date

Your name as it appears on you Driver's License:

How many years have you been licensed?

Driver's License State (if not Montana)

Have you had any traffic infractions in the last three (3) years?

YesNo

If yes, please explain the infraction(s).

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Is there anything on your driving record which would inhibit your ability to transport consumers?This job may require you to transport consumers to and from work, social functions, etc., either in your own vehicle or corporate vehicles.

YesNo

Please be prepared to provide a copy of your Driver’s License and verification of auto insurance.

Former Employers:

List former employers within the past 10 years, starting with most current first. Do not write “see resume”.

Company NameBusiness or Individual

AddressStreet, City, State

Job DescriptionDuties, Skills, Equipment Used

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Start Date

End Date

Phone Number

Reason for Leaving

Direct Supervisor's Name

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Company NameBusiness or Individual

AddressStreet, City, State

Job DescriptionDuties, Skills, Equipment Used

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Start Date

End Date

Phone Number

Reason for Leaving

Direct Supervisor's Name

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Company NameBusiness or Individual

AddressStreet, City, State

Job DescriptionDuties, Skills, Equipment Used

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Start Date

End Date

Phone Number

Reason for Leaving

Direct Supervisor's Name

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Company NameBusiness or Individual

AddressStreet, City, State

Job DescriptionDuties, Skills, Equipment Used

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Start Date

End Date

Phone Number

Reason for Leaving

Direct Supervisor's Name

Please feel free to attach a resume or use additional sheet to explain responsibilities and reasons for leaving.

Summary of Education:

Education Level

Less than High SchoolBeyond High SchoolGED or High SchoolOther

EducationIf Other, please explain.

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Professional References:

Please provide the names, addresses, and phone numbers for two work references who can attest to your skills and knowledge as they relate to this position, as well as your work habits.

Full NameProf Reference #1

AddressProf Reference #1

EmailProf Reference #1

Phone NumberProf Reference #1

Full NameProf Reference #2

AddressProf Reference #2

EmailProf Reference #2

Phone NumberProf Reference #2

Full NameProf Reference #3

AddressProf Reference #3

EmailProf Reference #3

Phone NumberProf Reference #3

Personal Reference:

Please provide the name, address, and phone number for a personal reference.

Full NamePersonal Reference #1

AddressPersonal Reference #1

EmailPersonal Reference #1

Phone NumberPersonal Reference #1

Full NameReference #2

AddressPersonal Reference #2

EmailPersonal Reference #2

Phone NumberPersonal Reference #2

Full NamePersonal Reference #3

AddressPersonal Reference #3

EmailPersonal Reference #3

Phone NumberPersonal Reference #3

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Skills/Experience:

For each of the skills/experiences listed below, check which of these has been a significant part of your past employment or training.

A. Supervisory Experiencepick all that apply

Report WritingBudgetingPublic RelationsStaff DevelopmentHiringEvaluating StaffConflict MediationProgressive DisciplineScheduling StaffQualityControl of Staff

B. Consumer Carepick all that apply

Working UnsupervisedExperience with Wheelchairs & Other Adaptive EquipmentMedication Certification/SupervisionPersonal CareHandling EmergenciesMenu Planning/Cooking/Grocery ShoppingPlanning/Training Recreational & Leisure ActivitiesWorking with Families or ParentsCounseling SkillsSocial Networking

C. Consumer Trainingpick all that apply

Writing Individual Program PlansImplementing Training ProgramsWriting Short & Long Range GoalsConducting AssessmentsData CollectionPrinciples of Behavior TherapyNon-Aversive Behavior ManagementConsumer RightsExperience with Alternative Methods of CommunicationSelf-Help SkillsSocial SkillsJob Coaching

D. Facility/Equipment/Vehicle Maintenancepick all that apply

Experience with Lift Equipment VehiclesRepair and MaintenanceYard WorkHousekeepingSafety Standards

E. Otherpick all that apply

DDCPT CertificationMarketingAccreditation StandardsCPR/First AidMANDT TrainingOffice Skills (list below)

Please list other skills that apply.

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Supporting Documents:

Use this file upload option to add your resume, references, copy of your driver's license, auto insurance, or other documents to this application.

Fileupload

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DISCLOSURE REGARDING BACKGROUND INVESTIGATION

IMPORTANT--PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION

RESOURCE, SUPPORT & DEVELOPMENT, INC. (“the Company”) may obtain information about you for employment/volunteer or contractor purposes from a third party consumer reporting agency. Thus, you may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, military history, social security verification, motor vehicle records (“driving records”), personal and professional reference checks, licensing and certification checks, etc. The information contained in the report will be obtained from private and/or public record sources, including sources identified by you or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, or other acquaintances.

The nature and scope of any investigative consumer reports that may be requested is explained above. You are nonetheless entitled to request more information about the nature and scope of such reports by submitting a written request to us.

The company will furnish you with a Summary of Your Rights under the Fair Credit Reporting Act in a form prescribed bythe Federal Trade Commission along with required state law notices in states where applicable

Social Security Number

Gender

MaleFemale

Maiden/Former Names:

Nicknames or AKAs

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the above DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" by the Company at any time after receipt of this authorization and throughout my assignment or employment, if applicable. I further understand that the Company may obtain “consumer reports” periodically during the duration of my employment with the Company for the purpose of making decisions related to my employment with the Company, and I authorize the Company to obtain “consumer reports” for this purpose. To this end, I hereby authorize, without reservation, any law enforcement agency, branch of the military, administrator, state or federal agency, institution, information service bureau, employer, or reference given to you by me to furnish any and all background information requested by the Company. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

By submitting this application, I certify that the facts in this application are true and complete to the best of my knowledge. I understand that any false or misleading statements or omissions on this application shall be a bar from being hired or, if discovered after hiring may lead to termination. I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information. I release all parties from all liability for any damage that may result from furnishing same to you.

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