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Expressions Unlimited — Employment Application
Please fill out all sections completely and accurately. Fields marked * are required. All information is kept confidential and used solely for employment consideration.

Applicant Information

Full Name *

Phone Number *

Email Address *

Home Address *

Social Security Number * 🔒 Stored securely and used only for background check purposes

Are you 18 years of age or older?

Yes No

Are you legally authorized to work in the United States?

Yes No

Do you have a valid New Mexico Driver's License?

Yes No

Do you have reliable transportation and current auto insurance?

Yes No

Position & Availability

Position Applied For *

Date Available to Start *

Program Preference *

Day-Hub (9am–3pm) Residential (3pm–11pm) Graveyard (11pm–9am)

Desired Employment Status *

Full-Time Part-Time PRN / On-Call

III

Education & Certifications

Do you have a High School Diploma or GED?

Yes No

Current CPR / First Aid Certification?

Yes No

Expiration Date

Other Relevant Certifications (CNA, Medication Aide, etc.)

Work Experience (most recent first)

Employer 1 — Most Recent

Employer Name

Your Role / Title

Start Date

End Date

Reason for Leaving

Employer 2

Employer Name

Your Role / Title

Start Date

End Date

Reason for Leaving

Background Check Disclosure

Caregivers Criminal History Screening Act (NMSA 1978, Section 29-17-1)

As a provider under the New Mexico DD Waiver program, all employees must undergo a nationwide criminal history screening. If you are selected as a finalist, you will be required to submit fingerprints to the Caregivers Criminal History Screening Program (CCHSP).

Abuse Registry Check: Prior to hire, your name will be checked against the:

New Mexico Employee Abuse Registry (EAR)
Office of Inspector General (OIG) List of Excluded Individuals
Consolidated Online Registry (COR)

Inclusion on any of these registries is a disqualifier for employment.

I have read and understand the background check and abuse registry disclosure above. *

Certification & Signature

What is meaningful to you as a possible employee? *

I certify that the information provided is true and complete. I understand that any false statements or omissions may result in disqualification or termination. * I acknowledge that employment is contingent upon: a clear result on the COR / Employee Abuse Registry, successful completion of a fingerprint-based background check within 20 days of hire, and maintaining NM DD Waiver training standards as required by the state. *

Electronic Signature — Type Your Full Name *

Date

Employment Application

Application Submitted!