Application Form

First name

Last name

Address

Apt/Unit/#

City

State

Zip Code

Phone

Are you 18 years of age or older?

Are you a United States Citizen?

Are you legally eligible for employment within the United States?

Have you served in the United States Armed Forces?

If Yes, please provide dates

Branch

Highest Rank

Duties & Skills

Are you a current member of the National Guard or Reserves?

If Yes, please provide your rank

Duties & Skills

Have you completed the Medi-Cal Peer Support Training?

If Yes, when?

Have you completed the Medi-Cal State testing?

If Yes, when?

Provide Peer Support Certification Number

Have you ever been diagnosed with any type of disability?

If Yes, please provide type(s) (Optional)

Please provide any history of lived experience in homelessness, mental illness, or justice involved (Optional)

Resume

Cover Letter (Optional)

Which position are you seeking?

Hourly salary desired (Optional)

What type of work are you seeking?

Are you available to work overtime?

When will you be available to work?

If hired, will you have reliable transportation to and from work?

Do you have a friend or relative employed by us?

If Yes, what is their name?