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So you watched the videos and you are ready to get a job where you can make a difference everyday. What are you waiting for?! Fill out our online employment application below and a team member from the respective program office will get in touch with you soon. We are excited to meet you!

Chrysalis is an equal opportunity employer and considers applicants for all positions without regard to race, color, religion, national origin, age, disability, veterans status, or any other protected status.

Chrysalis participates in E-Verify®.

Personal Information

First Name Initial Last Name Email

Current Address Apt City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code

Mailing Address (if different)   Apt City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code

Home Phone Cell Phone

Eligibility
Are you 18 years of age or older?	Yes No
Are you legally eligible to work in the United States?	Yes No
Have you ever been convicted of a crime other than a minor traffic violation?	Yes No
If yes please explain below. Each conviction will be judged in relation to time, seriousness, circumstances and relationship to the position sought and will not necessarily bar you from employment.

Employment Desired
Which Chrysalis region are you interested in?	Select a Region Utah Nevada
Which Chrysalis location are you applying for?	Select a Location Carson City Cedar City Ephraim Logan Nephi North Las Vegas Ogden Orem and Provo Park City Payson Price Reno Salt Lake City St. George
Employment desired	Full Time:     Part Time:
How did you find out about Chrysalis job opportunities?	Please Select Chrysalis Employee Friend Family Member Newspaper Classified Newspaper Color Ad Internet Job Listing UVSC Job Fair Chrysalis Website Other Details:
If a Chrysalis Employee referred you, please tell us who it was
Date you can start (mm/dd/yyyy)
Days and hours available to work (estimate)   Sun Mon Tues Wed Thur Fri Sat From Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm To Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm Any None 12am 1am 2am 3am 4am 5am 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm

Education

Name of School Year Completed Degree Earned Major/Subject High School College Other

General
Job Related Skills (typing, driver's license, volunteer work)

Former Employment

List below your last four employers, starting with the most recent.

Employer Phone No. Position/Duties End Wage Reason for Leaving Dates of Employment

References

Required: At least name and phone number for four people not related to you, whom you have known for at least one year.

Reference Name Address Phone No. Occupation Years Known

Previous Employment at Chrysalis
Have you previously worked for Chrysalis?	Yes No
Location
Supervisor
Position Held
Dates Employed at Chrysalis (mm/dd/yyyy)	From:    To:
Reason for Leaving

Nevada applicants must complete this section
Have you ever worked with any agency which contracts with the State of Nevada Developmental Services Region Centers (Desert, Rural, or Sierra Regional Center)?	Yes No
Have you ever worked for an agency, either within or outside the State of Nevada, that serves a vulnerable population e.g. children seniors, or developmentally disabled?	Yes No
Have you ever been accused (placed on re-assignment or administrative leave) in an abuse, neglect, or exploitation complaint and/or investigation?	Yes No
If so, were the accusations confirmed or substantiated? N/A Yes No
If yes, what was the outcome? (Check all that apply) N/A Termination Suspension Retrain Other
Provide more information as necessary

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