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Last Name First Name Middle Inital Home Address City State Zip Home Telephone Drivers License# Email Address
In Case of Emergency Notify:Name Relationship Telephone Address
Do you smoke / live with smokers? Why do you want to be a personal assistant? What personal strengths and/or special skills would you bring to this job? Do you have any direct care experience? If so, please describe: What challenges do you envision you might encounter in this type of work? How were you referred to PPA?
Are you a US Citizen? Yes No If no, do you have a legal right & necessary documents to work in the U.S.? (Identity & employment eligibility of all new hires will be verified as required by the Immigration Reform & Control Act of 1986.)
Were you ever discharged by any company? Yes No If yes, give name of company?
Have you ever been convicted of a crime other than a minor traffic violation? Yes No If Yes, please explain offense and final disposition:
EducationHigh School completion: College: Years Attended: Other training: Date Available Earliest morning start time Latest night end time
Employment History:May we contact your present employer? Yes No Past employer? Yes No Please indicate if you were employed under a different name.
Job #1Month/Year Started Month/Year Ended Employer Address Phone Job Title Supervisor Major Duties Reason for Leaving
Job #2Month/Year Started Month/Year Ended Employer Address Phone Job Title Supervisor Major Duties Reason for Leaving
Job #3Month/Year Started Month/Year Ended Employer Address Phone Job Title Supervisor Major Duties Reason for Leaving
References: Do not list relativesName Occupation Daytime Phone # Name Occupation Daytime Phone # Name Occupation Daytime Phone #
In submitting this application for employment, I understand that an inquiry will be made whereby information is obtained regarding my character, previous employment, general reputation, educational background, and/or criminal history. I authorize anyone possessing this information to furnish it to Partners in Personal Assistance (PPA) and I release anyone so authorized, & PPA, from all liability and damages whatsoever in furnishing, obtaining or using said information.
In the event of employment, I understand that false or misleading information given in my application or interview (s) may result in immediate dismissal. I understand I must abide by all policies & procedures set forth by the Board of Directors.
I understand and agree that if employed, the employment will be “at will”. That is, either I or PPA may end the employment relationship at any time, for any reason, or for no reason.
Please type your full name below to acknowledge that all of the information provided is both complete and accurate.Full Name
