Name: Street Address: City: State: Zip Code: Home Phone: E-mail:
When is the best time to contact you?
Are you applying for a position advertised on this website? Yes No
What position are you applying for?
Are you 18 years or older? Yes No
Do you have a valid driver's license? Yes No
Please check if you are available to work:
Part Time: Full Time:
Days: Yes No
Evenings: Yes No
Nights: Yes No
Saturday: Yes No
Sunday: Yes No
Two most recent jobs (Start with most recent)
1. Employer:
Employer's Address:
Dates Worked:
If currently employed, may we contact you employer?
Contact Person:
If yes, Employer's Telephone #
2. Employer:
Have you had any prior experience working with the developmentally disabled? If yes, please explain.
Highest Education Completed:
Phone: (518) 773-7931 or 888-703-7318 Fax: (518) 775-1333 E-Mail: hr@lexcenter.org