Blue Mountain Developmental Programs, LLC

623-584-5990

Blue Mountain Employment Application

First name

Last name

Birthday

Month

Day

Year

Position Applying For

Address

Country/Region

Address

City

Zip / Postal code

Phone

Are you over 18 years old?

Yes

Do you have one year of childcare, caregiving, education or recreation experience?

Yes

Do you have current CPR and First Aid certification?

Yes

Have you completed Article IX (9) Training?

Yes

Do you have or are you able to get a copy of your 39 month MVR?

Yes

Do you have an Arizona DPS Level 1 Fingerprint Clearance Card?

Yes

Have you ever been convicted of a felony?

Yes

If yes, please explain:

Have you previously worked for Blue Mountain?

Yes

If yes, provide month and year of separation.

How did you hear about us?

High School Attended

Did you graduate?

Yes

College Attended

Did you graduate?

Yes

Other training programs

Date available to start

Provide the name and phone number of THREE references who are not a relative or lives in your home. Please choose someone who will respond to our calls within 24 hours.

Current/Most Recent Employment

Address

Phone

Start Date

End Date

Reason for leaving

Previous Employment

Address

Phone

Start Date

End Date

Reason for leaving

Previous Employment

Address

Phone

Start Date

End Date

Reason for leaving

You may upload copies of CPR/First Aid, Article IX, Fingerprint Clearance Card, MVR Record, Car Insurance and Registration.

Please check the following boxes to indicate you agree.

I understand that a Pre-Employment Drug Screen may be part of the hiring process.

I understand that in compliance with Federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire.

I certify that my answers are true and complete to the best of my knowledge.

I authorize Blue Mountain Developmental Programs, LLC to search the Arizona Department of Economic Security (AZDES), Child Protective Services (CPS) Central Registry for my information.

I authorize the investigation of all statements contained in this application necessary to arrive at a decision to hire me and I understand that false or misleading information given in this application or interview may result in cancellation of my employment.

I understand that I am required to abide by all rules and regulations of BMDP, LLC and Arizona DES/DDD

Attendant Care Providers ONLY

I give permission for a representative of Blue Mountain to access and retrieve my Direct Care Worker testing records from the AHCCCS online database. I understand that the organization’s purpose in accessing the records is to ensure that employees meet the testing standards required by AHCCCS.

Direct Service Providers DTA Program ONLY

I decline to provide proof of current car insurance/registration at this time. I understand that I may not provide transportation in my personal vehicle for Blue Mountain.

I hereby authorize Blue Mountain to request my personal driving history for the past 39 months. I understand this inquiry will be made annually and kept in my employee file.

Signature

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