APPLICATION FOR EMPLOYMENT
-- Attendant Care Provider position --
PERSONAL INFORMATION    (Complete all applicable information - please include * items)
Name* (Full - Last, First, MI)
Position(s) applied for:
Are you willing to work: Full-Time Part-Time Temporary
Days Evenings Nights Weekends
Street Address:*
City:*
State:*
Zip:
Home Phone:*
Business Phone:
Email:*
Have you previously been employed by our agency? Yes No
Are you legally authorized to work in the U.S.? Yes No
When could you start
employment?
Have you ever applied for employment with our agency? Yes No
When?
If you are under 18 years of age, can you provide the required proof of your eligibility to work?
Yes No
EMPLOYMENT HISTORY    (list below last 3 employers starting with the most recent one first)
Present or Last Position:
Company Name:
Address:
From: (Mo./Yr.)   To: (Mo./Yr.)
Starting Annual or Hourly Salary:    Final Annual or Hourly Salary:
May we contact your supervisor? Yes No
Name of Supervisor:
Title & Department of
Supervisor:
Supervisor Phone Number:
Duties:
Reason for Leaving:
Present or Last Position:
Company Name:
Address:
From: (Mo./Yr.)   To: (Mo./Yr.)
Starting Annual or Hourly Salary:    Final Annual or Hourly Salary:
May we contact your supervisor? Yes No
Name of Supervisor:
Title & Department of
Supervisor:
Supervisor Phone Number:
Duties:
Reason for Leaving:
Present or Last Position:
Company Name:
Address:
From: (Mo./Yr.)   To: (Mo./Yr.)
Starting Annual or Hourly Salary:    Final Annual or Hourly Salary:
May we contact your supervisor? Yes No
Name of Supervisor:
Title & Department of
Supervisor:
Supervisor Phone Number:
Duties:
Reason for Leaving:
PROFESSIONAL REFERENCES    (REQUIRED if not listed on ATTACHED RESUME)
Name: Relation: Phone:
Name: Relation: Phone:
Name: Relation: Phone:
EDUCATION INFORMATION

High School or GED
City, State
Date Received 		 

College
City, State
Degree/Major
Date Received

College and/or
Graduate School
City, State
Degree/Major
Date Received
GENERAL
How did you learn about us? Newspaper Ad Radio Website/Internet
Friend (name) Relative (name)
Employment Agency Walk-In Other
Are you currently on "lay-off" status and subject to recall? Yes No
Can you travel if the job requires it and have reliable transportation? Yes No
Have you been convicted of a felony or misdemeanor within the last 7 years? Yes No
Conviction will not necessarily disqualify an applicant from employment.
Please list professional organizations, training/skills, special certifications and computer skills
relevant to this job:
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY   (Check boxes to proceed)

* In consideration of my employment, I agree to conform to the policies and procedures of the agency. I understand that in accepting this application, the agency is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time.

* I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application or omission of fact on either this application or during the pre-employment process will result in my application being rejected, or, if I am hired, in my employment being terminated.
* I also understand that any offer of employment is conditioned on the completion of pre-employment tests, background checks, and documentation. I will, upon request, sign all necessary consent forms.
Date: September 7, 2010      Signature:* (type name)
VOLUNTARY SURVEY
Government agencies at times require periodic reports on the sex, ethnicity, handicap, veteran, and other protected status employees. This data is for statistical analysis wth respect to the success of the Affirmative Action program. SUBMISSION OF THIS INFORMATION IS VOLUNTARY.
Check One:     Male     Female
Check one or more of the following (Ethnic Origin):
Caucasian Black American Indian Asian/Pacific Other
Alaskan Native Unknown Hispanic Filipino
Check if any of the following are applicable:
Veteran Disabled Veteran Handicapped Individual
Are you fluent in any other languages?
UPLOAD COVER LETTER AND/OR RESUME
Cover Letter: PDF or Word Document
Resume: PDF or Word Document