We are an equal opportunity employer.  We do not discriminate in hiring, promotion, or other employment decisions on the basis of race, sex, color, pregnancy, religion, disability, age, veteran status, sexual orientation, marital status or any other basis protected by law. Those applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the Human Resources Department.

Please do not complete this application until invited to do so by the family offering the position.

Personal Information

Employment History

(Please list the most recent employer first)


Office/Computer Skills

(Rank each skill on a scale from 1-4:   1-never used, 2-somewhat familiar, 3-familiar, 4-proficient)

Conviction Information

Employment is contingent upon an acceptable criminal record check, and that if a waiver is required, the waiver request is accepted by both the individual being supported or their guardian, and the State of NH.

Conviction information will not necessarily bar an applicant from employment.  If you leave this space blank, you are certifying that you have no current record of conviction.


Personal or Business References

(Do not include relatives or previously listed supervisors)

Acknowledgement and Authorization


  • I certify that all of the information that I provide on this application or in any interview will be complete, true, and accurate.  I understand that if I am hired, and any such information is later found to be incomplete, false, or misleading in any respect, I may be discharged.
  • If I am hired, I agree to abide by the rules and regulations of the Agency.
  • I understand that if I am applying for a position that would involve direct care, I may be asked to take a lifting test as a condition of employment.
  • I understand that if I am hired, my employment will be for no definite period, and that my employment and compensation can be terminated with or without cause and without notice, at any time, at the option of either the Agency or me.
  • I authorize all persons, companies, prior employers, schools, and government agencies to supply any information concerning my background, education, and employment, and release all parties from all liability for any damage that may result from furnishing same to you.  This may include credit checks for any position involving finances.  I also release the Agency and its agents from all liability from damages arising from this research of my background.
  • In the event I am hired, I authorize the Agency to provide information concerning my employment to prospective employers, and I release and hold the Agency harmless for providing such information.
  • I understand that Community Bridges will check the Office of Inspector General’s List of Sanctioned Individuals and Providers and the General Services Administration Excluded Parties Listing System both prior to hiring and on an annual basis.
  • I also understand that if I am employed by Community Bridges or its Affiliates and subsequently am convicted of any crime (a violation, misdemeanor, felony or any motor vehicle offense) or found to be in violation of a rule or any federal or state health care program, including Medicare or Medicaid, I must immediately notify Community Bridges Human Resources Office.  I authorize the Agency to investigate any of the facts set forth in this application.

I understand that this application will remain active for one year.  If I have not heard from the Agency by the end of one year and still wish to be considered for employment, I will need to complete a new application.

By signing below, I acknowledge I have read, understood, and agree to the above Notice Section.