Join our team.

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Part Time or Full Time *

Part Time

Full Time

Preferred Shifts *

Check all that apply

Days

Afternoons

Nights-Awake

Nights-Asleep

Are you authorized to work in the United States? *

Yes

No

Do you have a valid driver's license? *

Yes

No

Do you have reliable transportation? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

Have you ever received disqualification from DHS? *

Yes

No

Check highest lever of eduction you have completed: *

GED

High School Diploma

Some College

AA/AS

BA/BS

Graduate School

Start Date *

MM

DD

YYYY

End Date *

MM

DD

YYYY

Supervisor Phone Number *

(###)

###

####

Start Date *

MM

DD

YYYY

End Date

MM

DD

YYYY

Supervisor Phone Number *

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Supervisor Phone Number

(###)

###

####

Name

First Name

Last Name

Phone

(###)

###

####

*

I certify the information on this form is true and complete to the best of my knowledge. Falsification of application information will lead to disqualification from hiring process and/or immediate termination. I understand that the terms and conditions of my employment can be changed or terminated with or without cause, and with or without notice, at any time, by either myself or Bluewater Residential Services. If employed, I understand that in periods of low census or caseload I may have my hours reduced or be reassigned to other Bluewater residences.

I Agree