Employment Application Inside Cordia About Cordia Mission Core Values Founder’s Message History Cordia Happenings Cordia Weekly Join Our Team Cordia Culture Current Positions Appy Now Resources Testimonials Employment Application Application Date* MM slash DD slash YYYY Position applying for:*Department:Personal InformationName* First Middle Last Present Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Region ZIP Code Home Phone*Mobile PhoneEmail* If hired, when can you begin employment with Cordia?* MM slash DD slash YYYY Are you at least 18 years old?* Yes No This field is hidden when viewing the formBirth date MM slash DD slash YYYY This field is hidden when viewing the formCordia work historyHave you ever worked for Cordia previously? Yes No This field is hidden when viewing the formPlease provide job title, department, and dates of employment:This field is hidden when viewing the formAre you legally authorized to work in the United States?* Yes No Are you willing to work with individuals who may display challenging behaviors?* Yes No Are you able to provide physical assistance to individuals as needed?* Yes No Are you able to bend, kneel, lift (up to 25 pounds), stoop, stand and/or sit for long periods of time, work in a community environment, handle wheelchair requirements (if needed), with our without reasonable accommodation?* Yes No Educational HistoryAre you a high school graduate?* Yes No High school name & city, state location: Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Region School(s) beyond high school (please list names and locations of the schools):Graduated? Yes No Degree(s)/Certificate(s) Earned:Record of Employment (last 10 years)Cordia will confirm dates of employment, positions held, reasons for leaving with prior employers. Explain ALL gaps in employment and other information relevant to eligibility, qualification, and suitability with prior employers in the “Additional Information” section.Name of present or last employer:*Employer address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Region Full time or Part time?* Full time Part time Type of business*Name of supervisor*Phone*Start date* MM slash DD slash YYYY End date* MM slash DD slash YYYY Your job title*Starting pay*Ending pay*Reason for leaving*Description of work and responsibilities*Add 2nd employer? Yes No This field is hidden when viewing the formPrevious EmployerName of employerEmployer address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Region Full time or Part time? Full time Part time Type of businessName of supervisorPhoneStart date MM slash DD slash YYYY End date MM slash DD slash YYYY Your job titleStarting payEnding payReason for leavingDescription of work and responsibilitiesAdd 3rd employer? Yes No This field is hidden when viewing the formPrevious EmployerName of employer:Employer address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Region Full time or Part time? Full time Part time Type of businessName of supervisorPhoneStart date MM slash DD slash YYYY End date MM slash DD slash YYYY Your job titleStarting payEnding payReason for leavingDescription of work and responsibilitiesAdd 4th employer? Yes No This field is hidden when viewing the formPrevious EmployerName of employer:Employer address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Region Full time or Part time? Full time Part time Type of businessName of supervisorPhoneStart date MM slash DD slash YYYY End date MM slash DD slash YYYY Your job titleStarting payEnding payReason for leavingDescription of work and responsibilitiesAdd more employers? Yes No This field is hidden when viewing the formMore EmployersAdd additional employers, dates worked and description of dutiesUpload ResumeAccepted file types: doc, pdf, Max. file size: 128 MB.I understand that, if accepted for employment, I shall be required to provide proof of identity and eligibility to work in the United States (in compliance with the Immigration Reform & Control Act of 1986), as a condition of employment. In connection with this application, I authorize all corporations, companies, credit agencies, education institutions, persons, law enforcement agencies, military services, and former employers to release information that they may have about me to Cordia or its agents and release them from any liability for doing so. Also, I understand that a medical exam, pre-employment drug testing and/or criminal/abuse/neglect checks may be performed and that any offer of employment and continued employment is contingent upon receipt of satisfactory clearance. I understand that this application does not, by itself, create a contract of employment. I also understand that an acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I further understand and agree that, if accepted for employment by Cordia or its subsidiaries, I will have no expectation of privacy in the property owned by the organization. I understand that if employed, I have been hired at the will of my employer and that my employment may be terminated at any time, with or without cause and with or without notice. Confirmation of Accuracy*I understand that any misleading or incorrect statements may render this application void. I agree the company is not liable in any response if my employment is terminated because of false statements, answers, or omissions by me in the application. I agree. NameThis field is for validation purposes and should be left unchanged.
