NAME
ADDRESS
PHONE
Electronic
Date of Birth
SSN
Gender
Language
Emergency Contact
Formal
Informal
Work LimitationsList any work limitations that you may have and briefly describe:
Indicate Days and List Hours Available for Work
Client Types and Work Duties
Type of Position(s) Preferred
Clients Not Willing/Able
to Work With
Duties Not Willing/Able to Perform
Experience
Assignment Location
Type
Driver's License
Transporting Clients
Work Related #1 (Last Position)
Work Related #2 (2nd Last Position)
Work Related #3 (3rd Last Position)
Personal #1
Personal #2
I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Advocates for the Independent and I hereby release and discharge any of the above and Advocates for the Independent from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.
I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test ,if part of the Agency’s pre-employment policy.
I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.
