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APPLY ONLINE

"*" indicates required fields

Step 1 - Personal Data

Position Applying For

Date of Application*

Last Name*

First Name*

Middle Initial

Address*

City*

State*

Zip*

Phone*

Email*

Are you 18 years of age or older?*

Yes

No

Are you a U.S. citizen?

Yes

No

Have you ever been employed at DCH before?

Yes

No

If yes, when

Where

Do you have a record of founded child or dependent adult abuse or have you even been convicted of a crime, in this state or any state?*

Yes

No

I understand a pre-employment criminal history and child or dependent abuse record check will be performed.*

I Agree

Step 2 - Employment

Availability Date

Are you interested in working*

Full Time

Part Time

PRN

What shift are you willing to work*

Days

Nights

Any

Step 3 - Education

List of Diploma or Courses

Last High School

Did you Graduate

Yes

No

Name

College or University

Did you Graduate

Yes

No

Name

Other Vocational or Trade

Did you Graduate

Yes

No

Name

Special Training

Did you Graduate

Yes

No

Name

Step 4 - Professional Data

List Registrations, Certifications and/or License Numbers and Dates Received*

If Registration, Certification and/or Licenses are pending, when do you expect to obtain?

Step 5 - Employment History

List all employment beginning with your current or most recent past employer

Name of Employer #1*

Position Title*

Dates Employed

From

To

Address*

Duties*

Name of Supervisor*

Phone*

Email

May we contact this employer?

Yes

No

Reason for Leaving*

Name of Employer #2

Position Title

Dates Employed

From

To

Address

Duties

Name of Supervisor

Phone

Email

May we contact this employer?

Yes

No

Reason for Leaving

Name of Employer #3

Position Title

Dates Employed

From

To

Address

Duties

Name of Supervisor

Phone

Email

May we contact this employer?

Yes

No

Reason for Leaving

Step 6 - Statement of Health

Can you perform the essential functions of the positions for which you are applying?

Yes

No

If no, explain

Step 7 - Military Data

Veteran?

Yes

No

What type of training or experience did you receive in the service?

Date of Services

From

To

Branch of Service

Final Rank

Type of Discharge

Reserve Status