Employment Application - Langton Green

We understand your privacy concerns and will protect your information. Tell us about yourself. What’s your name and where do you live? How can we reach you?
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Cell Phone
Email*

How did you hear about job openings?
- Our web site
- Other internet source
- Langton Green staff
Staff Member Name
Are you related to or do you know a current or former Langton Green employee?
Name Relationship
Do you drive?
- Yes
- No
Is your license currently valid?
- Yes
- No
Which state issued your license?
Are you eligible to work in the United States?
- Yes
- No
Are you at least 19?
- Yes
- No
What current trainings do you hold?
Please select those applicable to you.
- CMT
- MANDT
- CPR
- FIRST AID
- Other
Other Trainings
When can you start working?
May we contact your current employer?
- Yes
- No

What position are you applying for?
Please check each box if you are applying for more than one position
- Direct Support Professional
- Program Manager
- Administration Staff
What is your expected rate?
Shift Availability
What works for you? These shifts are our most common but can vary. Please check all that apply.
- Sat-Sun 7a-11p
- Sat-Sun 9a-9p
- Mon-Fri 3p-9p
- Mon-Fri 3p-11p
- Awake Overnight Sun-Wed 11p-9a
- Awake Overnight Thurs-Sat 11p-9a
- Sublist (at least one 6-hour shift per month)
Would you be able to perform the essential functions of the positions chosen above, with or without reasonable accommodations?
- Yes
- No
What high school did you graduate from?
City/State
When
If you don't have a high school diploma, did you get your GED?
- Yes
- No
Where
When
Did you attend college?
Where When Degree
What other education have you pursued? What skills have you developed?

Now we’d like to hear about your work experiences. List as many as possible. Start with your most recent employer, and work backwards from there.
Work Experience
Name Supervisor City/State Duties Position Start Date End Date Why Left?
Tell us your thoughts. Why is it important to you to work with intellectually and developmentally disabled adults?
Are you involved? Do you volunteer in your community? What is the value of contributing to your community? What kind of volunteer activities have you participated in?
In your own words, explain a Direct Care Professional’s role and importance to our agency.
Are there past positions from which you were dismissed or asked to resign, or a position you resigned from to avoid being dismissed? If yes, explain:
- Yes
- No
Explanation of dismissal:
References
We’ll need at least three personal and/or professional references (but not family members). They should be people who have good insight into your skills, character, and abilities. Please provide, at the very least, a phone number and their first and last names.
Name Address Phone
Do you have any supervisory experience?
- Yes
- No
Supervisory Experience
Please list the position, location, and number of years you held that position.
Position Location # of Years

Initial 01

Under Maryland law, it is a misdemeanor offense for any employer to require an employee to take a lie detector test as a condition of employment.
Initial 02

Langton Green, Inc. does not discriminate in hiring on the basis of color, religion, national origin, sex, age, marital status, pregnancy, sexual orientation, genetic information, disability, or any other characteristic protected by law.
Initial 03

I have read the statements of this application and also certify that the information presented herein is complete and accurate. I further understand that withholding information or presenting false information on this application or during an interview will constitute grounds for immediate rejection of the application, or withdrawal of offer of employment if made, or termination from employment if hired.
Initial 04

I hereby give Langton Green, Inc. permission to verify any and all references listed herein, and to obtain verification from previous employers of employment dates, reasons for separation, results of performance evaluations, and any other information relevant to verification of performance.
Initial 05

I hereby give Langton Green, Inc. permission to obtain criminal background and driving history reports after I have signed an offer of employment, and to be enrolled in Maryland Vehicle Administration driver history monitoring at any time after hire.
Initial 06

I hereby agree, when requested, to participate in drug and/or alcohol testing at a facility designated by Langton Green, Inc.
Signature

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE STATEMENTS ABOVE AND THAT ALL INFORMATION PRESENTED IN THIS APPLICATION IS COMPLETE AND ACCURATE.

Name	Supervisor	City/State	Duties	Position	Start Date	End Date	Why Left?

Name	Relationship

Where	When	Degree

Name	Address	Phone

Position	Location	# of Years