Careers

EMPOWERMIND SERVICES LLC

EMPLOYMENT APPLICATION

232 South 3rd Street, Reading, PA 19602
484-529-9943
Info@empowermindservices.com
www.empowermindservices.com

Position Information

Position Applied For * Application Date *

1. APPLICANT INFORMATION

Full Legal Name * Preferred Name Address * City * State * ZIP Code * Phone * Email * Preferred Method of Contact * [radio* preferred-contact use_label_element "Phone" "Email" "Text Message"] Are you at least 18 years old? * [radio* age-18 use_label_element "Yes" "No"] Are you legally authorized to work in the United States? * [radio* authorized-work use_label_element "Yes" "No"]

2. POSITION & AVAILABILITY

Position Desired * Employment Status * Full-TimePart-TimePer Diem/PRN Availability DaysEveningsNightsWeekendsHolidays Earliest Available Start Date Preferred Weekly Hours Preferred Schedule/Days Willing to work in Berks and/or Chester County? * [radio* berks-chester use_label_element "Yes" "No"]

3. EDUCATION & TRAINING

Highest Education Level School/Institution Degree/Certificate Completion Date Relevant Training/Certifications Certifications CPRFirst AidMedication AdministrationDSP TrainingOther If Other, please specify

4. PROFESSIONAL EXPERIENCE

Most Recent Employer

Employer Name Job Title Supervisor Phone Employment Dates Reason for Leaving Primary Duties

Previous Employer

Employer Name Job Title Supervisor Phone Employment Dates Reason for Leaving Primary Duties

5. EXPERIENCE SUPPORTING PEOPLE WITH DISABILITIES

Experience working with individuals with intellectual/developmental disabilities? * [radio* disability-experience use_label_element "Yes" "No"] Years of Relevant Experience Types of Services/Supports Populations/Settings Served Relevant Skills

6. TRANSPORTATION / DRIVER INFORMATION

Will this position require participant transportation? * [radio* participant-transportation use_label_element "Yes" "No"] Driver's License State License Number License Expiration Date Can you provide required license/driving-record documentation? * [radio* driving-documentation use_label_element "Yes" "No"] If using a personal vehicle for authorized agency business, can you provide required insurance/vehicle documentation? * [radio* vehicle-insurance use_label_element "Yes" "No" "N/A"]

7. BACKGROUND CHECKS & CLEARANCES

Employment may be contingent upon required background checks, clearances, and screenings under applicable law and ODP requirements.

Willing to complete required checks and clearances? * [radio* background-check-consent use_label_element "Yes" "No"] Have you ever been disqualified from working with children or vulnerable adults? * [radio* disqualified-vulnerable-adults use_label_element "Yes" "No"] If yes, please explain

8. PROFESSIONAL REFERENCES

Please provide two professional references who are not relatives.

Reference 1

Name * Relationship/Company * Phone * Email

Reference 2

Name * Relationship/Company * Phone * Email

9. RESUME & DOCUMENTS

Resume/CV

Please upload your current resume. PDF, DOC, and DOCX files are accepted. Maximum file size: 5 MB.

Resume *

Driver's License / Certification Documentation

If applicable to the position, you may upload your driver's license, professional license, certification, or related documentation.

License/Certification Document

10. APPLICANT CERTIFICATION

I certify that the information in this application is true and complete to the best of my knowledge. I understand that material misrepresentation, omission, or falsification may result in denial of employment or termination if discovered after hire.

I certify that the information I have provided is true and complete to the best of my knowledge.

I authorize EmpowerMind Services LLC, where permitted by law, to verify information relevant to my application, including employment history, education, references, licenses, and certifications. I understand that required background checks and clearances must be completed before I may perform services for participants.

I authorize EmpowerMind Services LLC to verify information relevant to my application as described above.

I understand that submitting this application does not guarantee employment. If hired, I agree to follow the agency's policies, Employee Handbook, applicable law, ODP requirements, and participant-specific service plans.

I understand and agree to the statement above.

Electronic Signature

Applicant Full Name / Electronic Signature * Signature Date *

By typing my name above and submitting this application, I acknowledge that it represents my electronic signature for this application.

I agree that my typed name may be used as my electronic signature for this application.

Downloadable Application Form

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