Full Name: (First, M.I., Last) (required)
Best Contact Number (required)
Your Email (required)
Street Address (required)
Address line 2
City (required)
State (required)
Postal / ZIP Code (required)
Country (required)
Position Applying for: (required)
Have you ever been convicted of: (required) a crime?a felony?any type of Medicaid fraud?any type of abuse, neglect, or exploitation of a child or incapacitated adult?None of the above
If convicted of a felony, what State?
High School/GED - Where? Grade completed? (required)
College/Vocational School -- Where? When? Course of Study?
Do you have any special skills or abilities you would like to share with us? This includes any equipment you can operate, programs you are proficient using, awards, volunteer work, etc.
Please share the name, address, dates of employment, job duties and pay received for your last 2 employers: (required)
May we contact these employers? If not, who do you NOT want us to contact?
Reference Information: Please include the Name, Location, and phone number of 3 individuals who can be contacted and provide information about your character, work ethic, etc. (required)
Work Availability: Please check the options you can work. (required) Sunday : AnytimeSunday: 12 a.m. - 8 a.m.Sunday: 8 a.m. - 4 p.m.Sunday: 4 p.m. - 12 a.m.Monday: AnytimeMonday: 12 a.m. - 8 a.m.Monday: 8 a.m. - 4 p.m.Monday: 4 p.m. - 12 a.m.Tuesday : AnytimeTuesday: 12 a.m. - 8 a.m.Tuesday: 8 a.m. - 4 p.m.Tuesday: 4 p.m. - 12 a.m.Wednesday : AnytimeWednesday: 12 a.m. - 8 a.m.Wednesday: 8 a.m. - 4 p.m.Wednesday: 4 p.m. - 12 a.m.Thursday: AnytimeThursday: 12 a.m. - 8 a.m.Thursday: 8 a.m. - 4 p.m.Thursday: 4 p.m. - 12 a.m.Friday : AnytimeFriday: 12 a.m. - 8 a.m.Friday: 8 a.m. - 4 p.m.Friday: 4 p.m. - 12 a.m.Saturday : AnytimeSaturday: 12 a.m. - 8 a.m.Saturday: 8 a.m. - 4 p.m.Saturday: 4 p.m. - 12 a.m.
Please select any day of the week you are not available to work: SundayMondayTuesdayWednesdayThursdayFridaySaturday
I hereby certify information obtained on this application is true and correct to the best of my knowledge. I understand any false information or misrepresentation of facts disclosed on this application is cause for rejection of my application or discharge afer employment. West Virginia is an "At-Will" employment State and employment at JCDC is "at-will." I do understand and acknowledge this application is not a contract for employment or admission. Applications will be kept on file for six months to one year. **REASONABLE REQUESTS FOR ACCOMMODATIONS TO APPLY OR PARTICIPATE IN THE INTERVIEW PROCESS WILL BE HONORED.** Please type your full name below to confirm you have read and understand the previous statements. (required)
