NAME
First
2nd Initial
Last Name
ADDRESS
Street
Apartment
City
State
Zip
PHONE
Home
Cell
Other
Electronic
Email Address
Date of Birth
Day
Month
Year
SSN
Social Security Number
Gender
Language
What languages do you speak?
Emergency Contact
Local
Out of Area
Formal
Diploma
Certificate
Degree
Other
Other
Informal
Do you have current First Aid Certification (State Level)
Expiry Date
Do you have current CPR?
Expiry Date
Have you taken a Food Safety course?
Other Education (Specify)
Other Education (Specify)
Work Limitations List any work limitations that you may have and briefly describe:
Describe Hearing
Describe Speech
Describe Lifting
Describe Health
Describe Physical
Describe Emotional
Describe Other
Indicate Days and List Hours Available for Work
From
To
From
To
From
To
From
To
From
To
From
To
From
To
What is the minimum number of hours you will work in one day?
What is the maximum number of hours you will work in one day?
Client Types and Work Duties
Type of Position(s) Preferred
Other Description
Clients Not Willing/Able
to Work With
Other Specify
Duties Not Willing/Able to Perform
Other Specify Duties
Experience
Other Specify Experience
Assignment Location
Explain
Type
Vehicle Other Description
Driver's License
Do you have a valid Driver's License?
Transporting Clients
Are you willing to transport clients in your private vehicle?
Do you have adequate vehicle insurance?
Are you willing to drive a client’s vehicle?
Are you willing to escort a client in their own vehicle?
Are you willing to escort a client on public transportation?
Transporting Clients Comments
Abuse, If "yes", explain:
Work Related #1 (Last Position)
Company Name
Address
Telephone No & Email Address
Supervisor's Name
Position Held
Date of Employment
Reason for Leaving
Work Related #2 (2nd Last Position)
Company Name
Address
Telephone No & Email Address
Supervisor's Name
Position Held
Date of Employment
Reason for Leaving
Work Related #3 (3rd Last Position)
Company Name
Address
Telephone No & Email Address
Position Held
Supervisor's Name
Date of Employment
Reason for Leaving
Personal #1
Name
Address
Telephone No & Email Address
Nature of Friendship - Other than Relative (friend, co-worker, family etc.)
Personal #2
Name
Address
Telephone No & Email Address
Nature of Friendship - Other than Relative (friend, co-worker, family etc.)
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.
Electronic Signature:
Application Date
Optional - Upload Resume
Submit
