Today's Date
*
MM
DD
YYYY
Desired Position
Name
*
First Name
Last Name
Other Name You Have Previously Used
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Permanent Address (if different)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone
*
(###)
###
####
Email
*
Do you have a legal right to be employed in the U.S.?
*
Yes
No
Have you applied or worked at Community Life Services before?
Yes
No
If yes, when?
Do you have a current valid driver's license?
*
Yes
No
Do you have valid auto insurance?
*
Yes
No
Do you speak, write and understand English?
*
Do you speak, write and understand any other languages?
*
1.) Company Name
Job Title
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Company Phone
(###)
###
####
Employment Start Date
MM
DD
YYYY
Employment End Date
Leave blank if currently employed
MM
DD
YYYY
Are you still working for this employer?
Name of Supervisor
First Name
Last Name
# Hours Worked Per Week
Responsibilities
List the major job duties you performed
May we contact this employer?
Yes
No
2.) Company Name
Job Title
Company Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Company Phone
(###)
###
####
Employment Start Date
MM
DD
YYYY
Employment End Date
Leave Blank if currently employed
MM
DD
YYYY
Date you are available to start employment
*
MM
DD
YYYY
Are you still working for this employer?
Name of Supervisor
First Name
Last Name
Responsibilities
List the major job duties you performed
May we contact this employer?
Yes
No
# Hours Worked Per Week
How many hours / week are you available?
*
Check all that apply
Location(s) you prefer
*
Check all that apply
Mondays
*
Tuesdays
*
Wednesdays
*
Thursdays
*
Fridays
*
Saturdays
*
Sundays
*
Would you be willing to provide transportation for the individual(s) you might support?
*
Yes
No
Have you ever been convicted of a crime
*
Yes
No
If yes, please explain
City / State
Name of College or Trade School
Major Coursework
City / State
Did you graduate?
Yes
No
In Progress
Name of High School
*
Major Coursework
List any professional certifications, completed training courses, special training, or other job skills you possess
I agree to provide the following if offered employment: Local criminal history(ies), driver’s license, proof of eligibility to work in the U.S. (social security card, passport, birth certificate, or green card), satisfactory driving record, verification of current automobile insurance and registration, tuberculosis screening test and results, and a college degree if required for the position. I certify that the information provided in this document is true and complete to the best of my knowledge. I understand that misrepresentation or false or omitted facts will be sufficient cause for my dismissal, regardless of the time of discovery by the Agency. *
*
Initial and date
1.) Name
First Name
Last Name
Phone
(###)
###
####
Email
2.) Name
First Name
Last Name
Phone
(###)
###
####
Email
3.) Name
First Name
Last Name
Phone
(###)
###
####
Email
