NOVA CENTER OF THE OZARKS, INC. 524 S. Union Avenue Springfield, MO 65801 Phone: 417-889-3121 Fax: 417-881-2214

PLEASE DETACH THIS PAGE--IT IS YOURS TO KEEP!!!!

GENERAL EMPLOYMENT INFORMATION Nova Center of the Ozarks was incorporated in June of 1990 as a non-profit organization. Our five bed group home was opened in June of 1992 and closed in March of 2002 in order to provide more personal one on one care. Nova has now grown to include 13 ISL (Individualized Supported Living) homes in Springfield. Nova provides day habilitation in the form of our Community Supports program. Nova also provides various other services; however, we primarily hire for our Residential (ISLs) and Community Supports Programs.

Direct Support Professional (DSP): DSPs are responsible for monitoring the health and well being of Nova clients. Specific duties include: preparing meals, general cleaning, laundry, giving medications, taking clients into the community, and assisting with doctor and/or therapy appointments. Most residential shifts are evenings, overnights and weekends. A typical evening shift would be from 3pm-11pm. Overnights are typically from 11pm-9am. Day shifts during the weekend are typically from 8am-3pm. However, the hours may be slightly different depending on which facility you are assigned. The above times listed can be used as a general guideline.

Community Support Staff: Community Integration Staff in this program directly accompany and support individuals on community outings or in their natural home (i.e they live with parents/guardians or on their own). Shifts for this program are generally more flexible and are based on the consumer’s as well as their family’s needs. Staff is responsible for following the consumer’s personal plan and working on personal outcomes to allow the individual to become more independent in their community.

Personal Assistant Staff Personal Assistant staff also work with individuals who reside in their natural home. Typically, staff assist these consumers with their daily living needs such as: personal hygiene, nutrition, and other physical needs. Usually individuals who receive this service are adults with physical needs, but it is occasionally available to assist children with physical needs or challenging behaviors.

Basic Qualifications  Must be 18yrs of age or older  Must have a high school diploma or GED  Must have a valid driver’s license & social security card  Must have your own reliable transportation with proof of current car insurance and a good driving record *Proof of the above must be presented upon offer of employment

Certifications/Trainings (Provided and paid for by Nova) The following certifications are required*:  CPR-annually  First Aid-every 3 years  Mandt (Crisis prevention and intervention)-annually  Medication Administration-every 2 years  Abuse and Neglect-every 2 years  Autism and Behavior Support-new employee  General orientation-new employee Employment is contingent upon successful completion of drug screening. Nova Center of the Ozarks, Inc. 524 S. Union Avenue Springfield, MO 65802 Phone: 417-889-3121 Fax: 417-881-2214 Email: [email protected]

APPLICATION FOR EMPLOYMENT PERSONAL INFORMATION

Last Name First Middle Date

Street Address Apartment/Unit #

City State ZIP

Phone E-mail Address Business Cell Phone/ Other Phone Phone Company Name Phone ( ) Date Available Social Security No. Wage Expected Address Employed – FROM: TO: (Month & Year) Insert an X in the appropriate space to select your answer:

Have you ever applied for employment Name of Supervisor YES [ ] NO [ ] IfWeekly yes, date Pay START: LAST: with us? StateHave youJob Titleever andbeen employed here? YES [ ] NO [ ] IfComments yes, date Describe Your Work Part-Time Full-Time (Very Volunteer Educational Co-Op/Practicum/Intern Type of employment desired [ ] [ ] Limited) [ ] [ ] Direct Community Support Other, Specify: Support Staff ISL Manager Position desired Professional (Direct Care) [ ] ______[ ] [ ] [ ]

Yes No Are you able to meet the attendance requirements of the position? Reason for leaving [ ] [ ] Phone ( )

Yes No MayAre you we legally contact eligible for reference?for employment Yes No Later In the United States? [ ] [ ] [ ] [ ] [ ] Date(s) & Details: ______HaveOFFICE you USE ever ONLY: pled “guilty” Verified or “no contest” EligibleYes for rehireNo ______to or been convicted of a felony or SIS? If Answering “Yes” to these questions does not constitute an automatic bar to employment. Factors yes, please provide date(s) & [ details ] [ ][ ] [ ] such as date of offense, seriousness & nature of violation, rehabilitation and position applied for will be taken into account. EDUCATIONAL BACKGROUND

High School Address

------Did you graduate? YES [ ] NO [ ] Obtained GED Yes [ ] No [ ] Company Name Phone ( ) College Address Address Employed – FROM: TO: From To Did you graduate? YES [ ] NO [ ] (MonthDegree & Year)

Other Address Name of Supervisor Weekly Pay START: LAST:

StateFrom Job Title and To Did you graduate? YES [ ] NO [ ] CommentsDegree Describe Your Work EMPLOYMENT HISTORY

Please give an accurate and complete full-time and part-time employment record. Start with your present or most recent employer. Explain any gaps in employment in comments section. Please completely fill out Employer contact information (Name, Address, Phone).

Company Name Phone ( )

Employed – AddressReason for leaving Phone FROM:( ) TO: (Month & Year)

Name of Weekly Pay START: LAST: SupervisorMay we contact for reference? Yes No Later

[ ] [ ] [ ] State Job Title and Describe Comments Your Work

Reason for Phone ( ) leaving Verified Eligible for rehire OFFICE USE ONLY: [ ] [ ]

Company Name Phone ( )

Employed – Address FROM: TO: (Month & Year)

Name of Weekly Pay START: LAST: Supervisor

State Job Title and Describe Comments Your Work

Reason for Phone ( ) leaving

May we contact for reference? Yes No Later

[ ] [ ] [ ] Comments including explanations of any gaps in employment

Verified Eligible for rehire OFFICE USE: [ ] [ ]

SKILLS AND QUALIFICATIONS Why are you interested in working with people with developmental disabilities? Explain

Do you have experience working with individuals with developmental disabilities? Explain. Do you have any supervisory experience? Describe

Summarize any special training, skills, licenses and/or certifications that may qualify you as being able to perform job related functions in the position for which you are applying.

Additional Information:

REFERENCES

Please list three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you.

Name Length of time known

Phone ( ) Office Use Only:

Name Length of time known

Phone ( ) Office Use Only:

Name Length of time known

Phone ( ) Office Use Only:

ADDITIONAL INFORMATION (OPTIONAL) List professional trade, business or civic associations and any offices held, accomplishments, publications, awards, or any additional information you would like us to consider. (Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status).

PROSPECTIVE EMPLOYEE AVAILABILITY: (Remember we typically ONLY hire for Part-time (less than 39hrs/week). Please list the times each day that you are available to work for at least the next 120 days if hired. You must have some WEEKEND AVAILABILITY

You must be available to complete some training classes during the day based on the days they are scheduled.

**Your application will not be processed without this information** MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

How many hours per week are you hoping to work? MINIMUM: MAXIMUM: What outside commitments do you have that limit your availability?

Are you available for trainings held during the day? [ ] Yes [ ] No Comments:______

Are you available for weekend shifts? [ ] Yes [ ] No

Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employer’s service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

The Nova Center of the Ozarks is a drug-free workplace. Employment is contingent on successful completion of drug screening.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

X Signature of Applicant______Date ______

**Please allow at least 7-10 days to process your application once it is received. You will be contacted by phone if an interview is desired**

NOVA CENTER OF THE OZARKS, INC.

Driver Requirements Explanation for Community Based Services Staff Job/Position

One of the essential functions of this job/position is that you must be able to operate a motor vehicle and be able to aid and assist in the loading and unloading of clients/consumers/residents to and from motor vehicles, in everyday situations.

Some of the qualifications and requirements for this job/position are:

1. Must have a valid driver’s license with the proper class and endorsements. 2. Meet the qualifications as a driver; 3. Have a motor vehicle. 4. Proof of current auto insurance with verification of correct insurance company classification. We recommend you carry a minimum of at least $25/50/10 limit of liability and have the written permission of your insurance carrier for how you are using your vehicle for work purposes.

Please remember that driving is a necessary part of this job/position. You must be in compliance with all requirements and qualifications at all times. If you become non-compliant then you also will have to disqualify yourself for this job/position.

All jobs/positions are for the care and well being of the individuals we serve.

ACKNOWLEDGEMENT:

I have read and understand the above qualifications and requirements which are a part of this job/position. I do not have any questions. I will provide the necessary documentation upon the request of the employer’s representative. I understand that failure to provide the necessary documentation in a timely manner (as determined by the employer) will disqualify me for this job/position.

Signed on this date:______(mm/dd/year)

X Signature of Applicant/Employee (Print) Name of Applicant/Employee

Nova Center of the Ozarks, Inc. Employment Reference Check Date:______To Whom It May Concern:

The individual below has recently submitted an application for employment with our agency. Their signature below authorizes that the following information may be provided to Nova Center of the Ozarks, Inc. Thank you in advance for your cooperation.

Last Name: First Name: MI

Social Security#: Company Name:

Statement of Authorization I authorize you to provide any information and comments you may have regarding my performance and character. Signature of Applicant:______Date:______

Verification of Employment Information

Final Position Held: Employment Dates: From: To:

Additional Positions Held by Applicant:

Responsibilities/Duties:

Eligible for Rehire ___Yes ___No

Evaluation of Applicant Reason for leaving employment:

Please place a mark in the appropriate box below. Excellent Good Satisfactory Fair Unsatisfactory Attendance Additional Comments: Punctuality ______Initiative ______Team Work ______Quality of performance ______Signature______Title:______Date:______Signature______Title:______Date:______