Job Application

Contact Information

Name:

Social Security #:

Address:

How long have you lived at this address?

If you are a student, please give your permanent address:

Personal Information

If I prefer that you do not smoke while working, will it present any problems? Yes No

If I smoke while you are working, will it present any problems? Yes No

If I drink alcohol while you are working, will it present any problems? Yes No

Do you take drugs illegally? Yes No

Have you been convicted of a felony or misdemeanor or other offense, or been on parole or probation?
Yes No

If so, please explain:

Are you willing to fill out a background inquiry? Yes No

Do you have a valid driver's license? Yes No

Have you been convicted of a moving traffic violation in the last three years? Yes No

Have you been found more than 50% liable for a traffic accident in the last three years?
Yes No

If you have answered "Yes" to either of the previous two questions, please explain:

Do you have reliable transportation to work? Yes No

Do you have allergies to animals? Yes No

Are you sensitive to cleaning chemicals? Yes No

If so, which types?

Work Experience

What sort of personal experience do you have with people who have disabilities or medical needs?

What sort of work experience do you have with people who have disabilities or medical needs?

Can you lift transfer someone in and out of a wheelchair, bed or tub? Yes No

What languages do you speak?

How well can you read?

How well can you write?

Can you provide assistance with the following tasks:

Shopping? Yes No
Preparing food? Yes No
Cooking? Yes No
Washing clothes? Yes No
Ironing? Yes No
Vacuuming? Yes No
Light gardening? Yes No
Form filing / bill paying? Yes No
Caring for any animals I may have? Yes No

Are there any jobs you would not want to do (for example: drive, work for the opposite sex, or any duties listed in job description)?

Tell me briefly why you want to work as a personal assistant.

Work Schedule

How many hours per week are you willing to work?

Which days of the week are you willing to work?

Mon Tues Wed Thurs Fri Sat Sun

What hours of the day are you willing to work?

Could you work extra hours at short notice? Yes No

If you are a student, what is your class schedule?

What date are you available to start working?

If you are not hired, would you consider being an emergency backup? Yes No

References

List three former employers, beginning with the most recent one. Please be advised that I intend to contact your references.

1. Name of Employer:

Dates Employed:

Position Held:

Duties and Responsibilities:

Address:

Telephone number:

2. Name of Employer:

Dates Employed:

Position Held:

Duties and Responsibilities:

Address:

Telephone number:

3. Name of Employer:

Dates Employed:

Position Held:

Duties and Responsibilities:

Address:

Telephone number:

I hereby verify that all above information is true, and that none is misleading. If I am hired, and any of the information I have given is not true or is misleading, I understand that I may be fired at any time for this.

I permit my potential employer to conduct all background checks necessary, including contacting former employers, credit bureaus, schools and government agencies. I also hereby authorize all such persons and agencies to release information they may have about me to my potential employer.

Applicant's Signature

Applicant's Printed Name

Date

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