Local Address:

Permanent Address

Areas of Interest

Check All That Apply

IP (Intellectual Disability programs – Must be 18 years of age or older)
MH (Mental Health)
Early Intervention (Licensed Therapist/Certified Teachers Only)
Life Link
Internship
Part Time
Full Time
No Preference

Additional Information

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Yes No
Yes No
Yes No

If you checked “Yes” to either of the last two questions, please explain below.

Criminal history clearances will be reviewed for all hires.

Education

Select Type of School From Drop Down List






List other experience or special skills that would qualify you for the position for which you are applying.

List special current certifications and licenses; list other appropriate in-service training.

Employment Background

Start With Most Recent Employer

Employer 1

TO

Employer 2

TO

Employer 3

TO

Availability

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Please List Daily Hours of Availability

I hereby certify that all information made on or in connection with this application is true and complete to the best of my knowledge and belief. I have not knowingly withheld any facts or circumstances. I understand that any misrepresentation of or concealment of material fact will be sufficient grounds for rejection of my application or removal from employment. I authorize my present and previous employers to release any information they may have regarding my character and/or my employment record to Strawberry Fields, Inc. I release said employers from any damage or claim for furnishing said information. I understand that this employment application and any other company documents are not contracts of employment, and that any individual who is hired may voluntarily leave employment upon proper notice, and may be terminated by the employer at any time for any reason. I understand that any oral or written statement to the contrary are hereby expressly disavowed and should not be relied upon by prospective or existing employee.

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References

Professional

List at least three professional references from employers, not friends or relatives who have knowledge of your character, experience, and ability.

Professional Reference 1


Professional Reference 2


Professional Reference 3

Personal

List at least three personal references from friends or relatives, not employers, who have knowledge of your character, experience, and ability.

Personal Reference 1


Personal Reference 2


Personal Reference 3


I (insert name) expressly authorize Strawberry Fields, Inc. to make an inquiry of my former employers concerning my work record, job qualifications, performance, and character. I authorize my former employer to furnish Strawberry Fields, Inc. with this information. I recognize the right of Strawberry Fields, Inc. to treat, at its discretion, certain sources as confidential, and its right to withhold from me or my agent, the names of such confidential sources, and information obtained there from.

Agree Disagree