Strawberry Fields, Inc. Online - []
SFI Application

Applicant's Information
Name
E-mail Address
Local Address:
Local Address:
Address
City, State ,
Zip
Telephone
Permanent Address:
Address
City, State ,
Zip
Telephone

Areas of Interest (check all that apply)
DP (Developemental Disability Programs) Life Link
MH (Mental Health) Part Time
Full Time Early Intervention (Licensed Therapist/Certified Teachers Only)
No Preference Internship

Additional Information
Position Applied For
Date when you would be available for work:
Were you referred by anyone from the agency?
How did you learn of this position?
Do you have a valid Driver's License? Yes      No
Have you been a resident of PA for at least two years? Yes      No
Have you ever been convicted of a crime? Yes      No
Do you have any charges pending against you? Yes      No

If you checked "Yes" to either of 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)
Name
Address
Major 
Years Completed
Degree Received

Name
Address
Major    
Years Completed
Degree Received

Name
Address
Major 
Years Completed
Degree Received

Name
Address
Major 
Years Completed
Degree Received

Name
Address
Major 
Years Completed
Degree Received


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)
Name of Employer
Address
Telephone Number
Name of Supervisor  
Employed from to
Title
Salary  
Duties
Reason for Leaving


Name of Employer
Address
Telephone Number
Name of Supervisor  
Employed from to
Title
Salary  
Duties
Reason for Leaving


Name of Employer
Address
Telephone Number
Name of Supervisor  
Employed from to
Title
Salary  
Duties
Reason for Leaving

Availability
Are you available to work weekends? Yes       No
Are you available to work Holidays? Yes       No
Are you available to work evenings? Yes       No
Are you available to work days? Yes       No
Are you available to work sleepovers? Yes       No
Are you available to work during semester breaks (i.e. Winter break, Spring Break, and Summer)? Yes       No
How many hours are you looking for in a part-time position?


Please list daily hours of availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday


How long of a time commitment are you willing to make to the agency?


     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 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.

Agree       Disagree


References

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

Name
Email Address
Telephone   

Name
Email Address
Telephone   

Name
Email Address
Telephone   


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

Name
Email Address
Telephone   

Name
Email Address
Telephone   

Name
Email Address
Telephone   


     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 release said employer from any damage or claim for furnishing said 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


    

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