Careers

Application for Employment

Chrysalis SLS Is an Equal Opportunity Employer
To be considered for employment at Chrysalis SLS, please fill in this form completely. If you cannot respond to an item, please explain your reason for not responding on the back of the page. An incomplete application is not considered an application for employment with us. Please print clearly.

Chrysalis SLS is an equal opportunity employer and prohibits discrimination and harassment of any kind. Chrysalis SLS is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment.

All employment decisions at Chrysalis SLS are based on business needs, participant's needs and desires, job requirements, and individual qualifications without regard to race, color, religion or belief, national, social or ethnic origin, age, physical, mental or sensory disability, pregnancy, HIV Status, gender, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, personal and family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. Chrysalis SLS will not tolerate discrimination or harassment of any kind. All candidates will be required to undergo a pre-employment drug screening (not cannabis).

Currently, the State of California requires all healthcare workers to be vaccinated against Covid-19

Today’s Date
MM slash DD slash YYYY
PERSONAL INFORMATION
Last Name
First Name
Present Address
Apt. # City State Zip
Are you 18 years or older?
- Yes
- No
Telephone:
Alternate Telephone
DESIRED EMPLOYMENT
Position
Date you can start
MM slash DD slash YYYY
Are you currently employed?
- Yes
- No
If so may we inquire of your present employer?
- Yes
- No
Applying for:
- Full-time
- Part-time time
Days and Hours available to work:
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Available to work:
- Days
- Evenings
- Weekends
- Overnights
Why are you applying for work at Chrysalis SLS?
Ever applied/Worked for Chrysalis SLS?
- Yes
- No
Where?
When?
Reason for leaving?
Who referred you to Chrysalis SLS?
- On-Line Search
- Newspaper Advertising
- Friend
- State Employment Office
- College Placement
- Walk in
- Other
EDUCATION
School Level (High School / College / Trade, Business, Correspondence school)
Name and Locations No. of Years Graduate Subject Studied
GENERAL
Subjects of special study or research work
Special training
Special skills
FORMER EMPLOYERS
(List below the last four employers, starting with the most recent)
Name of current or last employer
Address City State Zip
Starting date
MM slash DD slash YYYY
Leaving date
MM slash DD slash YYYY
Job Title
Name of Supervisor
Title
Phone
May we contact your supervisor?
- Yes
- No
Description of Work
What did you like most about your job?
What did you dis-like about your job
Reason for leaving:
Name of previous employer
Address City State Zip
Starting date
MM slash DD slash YYYY
Leaving date
MM slash DD slash YYYY
Job Title
Name of Supervisor
Title
Phone
May we contact your supervisor?
- Yes
- No
Description of Work
What did you like most about your job?
What did you dis-like about your job
Reason for leaving:
Name of previous employer
Address City State Zip
Starting date
MM slash DD slash YYYY
Leaving date
MM slash DD slash YYYY
Job Title
Name of Supervisor
Title
Phone
May we contact your supervisor?
- Yes
- No
Description of Work
What did you like most about your job?
What did you dis-like about your job
Reason for leaving:
Name of previous employer
Address City State Zip
Starting date
MM slash DD slash YYYY
Leaving date
MM slash DD slash YYYY
Job Title
Name of Supervisor
Title
Phone
May we contact your supervisor?
- Yes
- No
Description of Work
What did you like most about your job?
What did you like least about your job?
Reason for leaving
REFERENCES:
(Name three people you are not related to, whom you have known at least three years.)
NAME ADDRESS PHONE EMPLOYER YEARS KNOWN
Chrysalis SLS requires DOJ fingerprints for all employees
Do you own a reliable automobile?
- Yes
- No
If yes, do you have proof of current auto insurance, registration and driver's license?
- Yes
- No
Do you have use of this automobile at any hour of any day?
- Yes
- No
Can you, and are you willing to lift 25 pounds or possibly more?
- Yes
- No
Please read carefully, acknowledge each paragraph by initialing, and sign below.*
- I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application and for immediate discharge if I am employed, regardless of the time elapsed before discovery.
*
- I hereby authorize Chrysalis SLS to thoroughly investigate my references, work records, education, and other matters related to my suitability for employment with adults who have developmental disabilities and, further, authorize the references I have listed to disclose to Chrysalis SLS any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release Chrysalis SLS, my former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.
*
- I understand that, the business of Chrysalis SLS is based on serving its clients’ choices and needs. Therefore, Chrysalis SLS cannot promise or guarantee any quantity of hours of work or any work at all. Chrysalis SLS makes no promise of duration of employment and there is no contract of any kind expressed or implied between Chrysalis SLS and its employees. No specific days, dates or times of work is promised. No work with any particular client is guaranteed.
*
- I understand that nothing contained in this application or conveyed during any interview that may be granted or during my employment, if hired, is intended to create an employment contract between me and Chrysalis SLS. In addition, I understand and agree that Chrysalis SLS is an At-Will employer and if I am employed, my employment is for no particular duration and may be terminated at any time, with or without notice and with or without cause by myself or Chrysalis SLS, and that no promises or representations to the contrary are implied in any way.
*
- Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted by internal personnel employed by Chrysalis SLS, I am entitled to copies of any such public records obtained by Chrysalis SLS unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.
*
- I waive receipt of a copy of any public record described in the paragraph above.
Printed name of Applicant
Applicant’s Signature
Max. file size: 100 MB.
Date
MM slash DD slash YYYY

Name and Locations	No. of Years	Graduate	Subject Studied

NAME	ADDRESS	PHONE	EMPLOYER	YEARS KNOWN

Careers

Application for Employment

PERSONAL INFORMATION

DESIRED EMPLOYMENT

EDUCATION

GENERAL

FORMER EMPLOYERS

REFERENCES: