Application for Employment

Judevine^® Center for Autism is always expanding and we would love to hear from you. Please fill out the form below and sign it at the end. It will automatically send us a copy via email and then we will start the reviewing process!

Step 1 of 3

Today's date*
MM slash DD slash YYYY
Email*
Full Name*
Address*
Street Address Address Line 2 City State ZIP Code
Cell Phone
Home Phone
Position(s) Applying For*
- Autism Specialist
- Direct Support Professional
- Registered Behavior Technician
- Supported Living Home Manager
- Other
Location(s) applying for*
- St Louis Metro
- Jefferson County
- Northwest Missouri (Hannibal & Kirksville)
- Southwest Missouri (Springfield & Joplin)
What locations are you interested in applying for?
How did you hear about Judevine?
Salary Desired:
Available Hours, Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
How many hours can you work weekly?*
Can you work weekends/evenings/overnights?
Employment Desired:
When are you available to start work?*
MM slash DD slash YYYY
Have you ever been convicted of a felony or serious misdemeanor?
If so please explain about felony/serious misdemeanor:
Have you ever had an abuse/neglect claim substantiated against you?
If so please explain about abuse/neglect claim:
Do you have a driver's license?*
State:
Driver's License Number:
Do you have auto insurance?

Education & Other Information
High School:
Location:
# of years completed:
High School Diploma:
GED:
College:
Location:
# of years completed:
Major & Degree
Bus. or Trade School:
Location:
# of years completed:
Major & Degree
Professional License/Certification
License/Certification(type):
License/Certification #:
Please list two references other than relatives or previous employers.
Name (Reference #1):
Name (Reference #2):
Position (Reference #1):
Position (Reference #2):
Company (Reference #1):
Company (Reference #2):
Phone (Reference #1):
Phone (Reference #2):
Address (Reference #1):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Address (Reference #2);
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Experience
Please List your work experience for the past 5 years beginning with your most recent job held. If you were self-employed, give the firm's name. Attach resume and additional sheets if necessary at the end of this page.
Job #1
Dates Employed from:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Employment:
if part-time, #hrs./wk:
Title:
Starting Salary:
Finishing Salary:
Organization Name:
Address of Organization:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor's Name:
First Last
Title:
Phone Number:
Oher Reference Name:
First Last
Title:
Phone Number:
Contact my current references:
Primary Duties:
Reason for Leaving:
Job #2
Dates Employed from:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Employment:
if part-time, #hrs./wk:
Title:
Starting Salary:
Finishing Salary:
Organization Name:
Address of Organization:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor's Name:
First Last
Title:
Phone Number:
Oher Reference Name:
First Last
Title:
Phone Number:
Contact my current references:
Primary Duties:
Reason for Leaving:
Job #3
Dates Employed from:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Employment:
if part-time, #hrs./wk:
Title:
Starting Salary:
Finishing Salary:
Organization Name:
Address of Organization:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor's Name:
First Last
Title:
Phone Number:
Oher Reference Name:
First Last
Title:
Phone Number:
Contact my current references:
Primary Duties:
Reason for Leaving:
Use the space below to add any additional information to describe why you are qualified for this position
Resume If you have one:
Drop files here or

Max. file size: 30 MB.
Please Read Carefully
By clicking Submit, you agree to the following Application Waiver
In exchange for the consideration of my job application by Judevine I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Judevine practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Judevine, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /Director of Judevine.

Both the undersigned and Judevine may end the employment relationship at any time, without specified notice or reason. If employed, I understand that Judevine may unilaterally change or revise their benefits, policies, and procedures and such changes may include a reduction in benefits. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Judevine permission to contact schools, previous employers (unless otherwise indicated), references, and others and hereby release Judevine from any liability as a result of such contact. I also understand that (1) Judevine has a drug and alcohol policy that provides, upon request, pre-employment testing, as well as testing after employment upon request; (2) consent to and compliance with such policy, is a condition of my employment; and (3) employment and/or continued employment is based on the successful passing of testing under such policy. I further understand that my employment with Judevine shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relationship with Judevine is terminable at will for any reason by either party.

Judevine is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, veteran status, age or disability. We assure you that your opportunity for employment with Judevine depends solely on your qualifications.

Application for Employment

Step 1 of 3

Education & Other Information

Professional License/Certification

Please list two references other than relatives or previous employers.

Work Experience

Job #1

Job #2

Job #3

Please Read Carefully