Sponsorship Application

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Sponsorship Application

Application must be filled out in its entirety; this form serves as an official document to IMPACT, State Licensing Inspector and Human Right Officials.

Application Information

Name

First

Last

DOB

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country / Region

Phone

Date Available

Desired Salary

Social Security

Position Applied for

Are you a citizen of the United States?

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for this company?

Yes No

If so, when?

Have you ever been convicted of a felony?

Yes No

If yes, explain

Education

High School

Address

Street Address

City

State / Province / Region

Postal / Zip Code

Country / Region

From

Did you graduate?

Yes No

Degree

Other

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country / Region

From

Did you graduate?

Yes No

Degree

References

Please list three Professional references.

First

Last

Relationship

Company

Phone

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country / Region

Name 2

First

Last

Relationship

Company

Phone

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country / Region

Name 3

First

Last

Relationship

Company

Phone

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country / Region

Previous Employment

Company

Phone

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country / Region

Supervisor

Job Title

Ending Salary $

Starting Salary $

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Company

Phone

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country / Region

Supervisor

Job Title

Ending Salary $

Starting Salary $

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Driver's License

State Authorized in:

Driver’s License Number:

Type of License

Employment Licenses (Ex. Nursing, LCSW, CNA)

Type of License

Issuing Date

Do You Have experience in the field of Intellectual development disabilities?

Explain how you gained your experience in the areas above? Use additional paper if needed.

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial and other related matters as may be for an employment decision. I hereby release employers, schools, or individuals from all liability when responding to inquiries in connection with my application.

In the event I am employed, I understand that false or misleading information given in my application or interview (s) may result in termination of my employment without cause.

Upload Resume (If Needed)

Signature

Date and Time

An Equal Opportunity Employer

No Applicant shall be discriminated against by the agency or agency employees on the basis of race, creed, color, religion, sex, national origin or age.

Community Partners

Thank you for your support from our Community Partners.

Community Partners

Thank you for your support from our Community Partners.

We serves Individuals in a fostering environment; allowing each individual the opportunity to experience a family atmosphere. Each family that has committed to supporting an Individual is qualified through comprehensive annual trainings. No household can exceed two individuals.

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