The Independent Living Center

Name

Date

Address

City

State

Zip

Phone

Are you 18 years or older?

Yes

No

Are you prevented from lawfully becoming employed in the United States

Yes

No

Are you willing and able to:

Lift at least 50 pounds?

Yes

No

Use own vehicle for your job?

Yes

No

Desired Salary (per hour)

What experience have you had that would be relevant to being a Personal Care Assistant to a person with a disability?

Availability

How many hours per week do you wish to work?

Day	Hours Available
Monday
Tuesday
Wednesday
Thursday
Friday

Job Activities

Please check any and all areas you are experience and willing

Personal Care:

Dressing

Grooming

Shower/Bath

Housekeeping:

Cooking

Cleaning

Laundry

Shopping/Errands

Will You Work For:

Men

Women

Smokers

Clients with Pets

Pertinnent Education and Certifications

High School or Institution	Dates Attended	Diploma or Certification Earned

Work History

List your last 3 employers below, starting with the most recent /current first

From	To	Employer	Phone

May we contact your current employer?

Yes

No

References

Give the names of at least 2 personal references

Name	Address	Phone

Have you ever been convicted of a felony or misdemeanor?

Yes

No

Please list all criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo contendere, except minor traffic violations. Include any suspended imposition of sentence, any suspended execution of sentence or any period of probation or parole. THIS MUST BE COMPLETED TO BE CONSIDERED FOR HIRE.

Year of Incident	Violation	Please Explain

Please list all states you have lived for the past 5 years

Disclaimer Signature

I certify that the information on this application submitted by me is true and complete and I understand that any false information, omissions, or misrepresentations may cause my application to be rejected, or, if employed, my employment to be terminated. I authorize you to contact the above persons regarding my prospective employment with The Independent Living Center. I further authorize TILC to conduct background and employee disqualification checks and understand that employment may be contingent upon the outcome of said checks and a drug test.

Signature

Date

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