EMPLOYMENT APPLICATION
EMPLOYMENT APPLICATION
NAME: DATE:_________________
STREET ADDRESS: CITY:__________________
STATE: ZIP: SOCIAL SECURITY #_________________
HOME PHONE NUMBER: OTHER:__________________
Date available for employment: ______________________
How many hours a week can you work? ________________
Are you interested in a live-in position? (If Applicable) __YES NO
Are you interested in serving as a back-up assistant? __YES NO
ANSWER THE FOLLOWING QUESTIONS:
1) Why do you want to be a personal assistant?
2) Have you ever been convicted of a crime, plead guilty or no contest to a crime, or received deferred adjudication for any offense? If so, please explain. [A criminal conviction record must be verified before an offer for employment may be made to an applicant.]
3) Do you have a valid Texas driver's license? ___YES NO
4) Are you certified in CPR? ___YES, [Effective Date _______; Expires on: ______] ____ NO
CPR Certification is a condition of employment. If you are not certified, are you willing to be certified? ___ Yes ___ No
LIST ALL JOBS YOU HAVE HAD BEGINNING WITH THE MOST RECENT:
EMPLOYER'S NAME: ______________________________________________________
DATES OF EMPLOYMENT:______________________________________________________
EMPLOYER'S ADDRESS________________________________________________________
PHONE NUMBER: _____________________ SUPERVISOR’S NAME:___________________
DESCRIPTION OF WORK DUTIES:________________________________________________
REASON FOR LEAVING________________________________________________________
**********************************************************
EMPLOYER'S NAME: ______________________________________________________
DATES OF EMPLOYMENT:______________________________________________________
EMPLOYER'S ADDRESS________________________________________________________
PHONE NUMBER: _____________________ SUPERVISOR’S NAME:___________________
DESCRIPTION OF WORK DUTIES:________________________________________________
REASON FOR LEAVING________________________________________________________
**********************************************************
Employment Application / Page 2 of 2 Applicant Name: ___________________
EMPLOYER'S NAME: ________________________________________________________
DATES OF EMPLOYMENT:___________________________________________________
EMPLOYER'S ADDRESS_______________________________________________________
PHONE NUMBER: ____________________ SUPERVISOR’S NAME:___________________
DESCRIPTION OF WORK DUTIES:______________________________________________
REASON FOR LEAVING_______________________________________________________
**********************************************************
EMPLOYER'S NAME: ________________________________________________________
DATES OF EMPLOYMENT:___________________________________________________
EMPLOYER'S ADDRESS_______________________________________________________
PHONE NUMBER: ____________________ SUPERVISOR’S NAME:___________________
DESCRIPTION OF WORK DUTIES:______________________________________________
REASON FOR LEAVING_______________________________________________________
**********************************************************
LIST THREE PERSONAL REFERENCES:
1______________________________________________________________________
(Name) (Address) (Phone Number)
2._____________________________________________________________________
(Name) (Address) (Phone Number)
3._____________________________________________________________________
(Name) (Address) (Phone Number)
**********************************************************
What skills or experiences do you have related to being a personal assistant?
Applicant Acknowledgement:
If offered a position, will you be able to be at work on time and according to the schedule discussed? __ Yes ___ No Comments______________________________________
I, the applicant, verify that the information provided is true and correct to the best of my knowledge. I also acknowledge that a Criminal Conviction Check is required and that some convictions prevent employment. I also acknowledge that an employee must have and maintain current certification in CPR.
Signature: _________________________________ Date of Signature:___________
Received by: ____________________________ Date: ______________
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