* = Required Information
Date of Application *

Restoration Health Services, LLC is an Equal Opportunity Employer. Hiring decisions will be made without regard to race, color, creed, religion, national origin, age, gender, presence of any sensory, mental or physical disability, marital status, disabled status or veteran status, sexual orientation or any other reason prohibited by Federal, Washington, or local law; unless such decision/ action is based upon bona fide occupational qualification.

Position(s) applying for *
Willing to accept *                     Fulltime Part Time Interminent Temporary
Shift(s) available to work *         Day Evening Night Weekends
Date you can start:         Salary desired:

PERSONAL INFORMATION
Last Name * First Name * Middle Name *
 		Phone *
Street Address *
 		Cell Phone
City * State Zip *
 		Email Address *
Other Name(s) (i.e. married, maiden, alias)
 		Are you 18 Yrs or Older?
 YesNo
Are you either a U.S Citizen or Alien Authorized to work in the United States?
 YesNo 		Were you in the US armed Forces?
 YesNo
(if so, dates: )
Do you have a Washington State Drivers Licensed?
 		Do you have car insurance?
EDUCATION Name and Location of School No. Of Years Attended Did You Graduate? Subjects Studied
High School
College
Business/Trade/Technical
Other Education/Certificates/Special Skills:

References: Give the names of three persons not related to you, whom you have known at least one year.

NAME PHONE NO: BUSINESS YEARS KNOWN
1.
2.
3.
INCASE OF EMERGENCY NOTIFY :
First Name
 Last Name
 Relationship
 Phone No.

Employment History- begin with most recent employer.

Employer Direct Supervisor:
Job Title: Telephone:
Duties: Address:
Start Date:
 End Date :
Beginning Pay:
 Ending Pay:
Reason for leaving

Employer Direct Supervisor:
Job Title: Telephone:
Duties: Address:
Start Date:
 End Date :
Beginning Pay:
 Ending Pay:
Reason for leaving

Employer Direct Supervisor:
Job Title: Telephone:
Duties: Address:
Start Date:
 End Date :
Beginning Pay:
 Ending Pay:
Reason for leaving

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. 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 they may have and release all parties from all liability for any damage that may result from furnishing same to you.

I understand that, if hired, that the company offers no employment contract, or guarantee of shift, hours, benefits or wages. I understand that my employment will be of an indefinite time, and either the company or I may terminate employment with or without cause. I understand that any representation otherwise are null and void. This policy may be altered or amended only by and with written consent of the President of Restoration Health Services, LLC.

REQUIREMENTS FOR EMPLOYMENT:
Successful background inquiry cleared by the authorized state agency. Until clearance is received, employee is unable to work alone with clients

We must receive a negative report on pre-employment drug test from test lab selected by Restoration Health Services. Be eighteen years of age or older and have attained a high school diploma or GED equivalent.

A demonstrated ability to work with developmentally disabled adults; minimum requirements must be met in accordance with WAC 275-26-060 Demonstrate the ability to be an appropriate role model and exhibit mature behavior and ability to make independent judgments.

Date:       Signature of Applicant *
Security Code *