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Application for Employment
Name
First
Middle
Last
Address
City
State
Zip Code
Home Phone
Cell Phone
Email
*
Position Applying For
Type of Employment You Are Seeking
Regular
Summer/Seasonal
Part Time
Temporary
Full Time 35+
If Summer, Seasonal, or Part Time: (Optional)
Start Date
End Date
Days Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Questions (1-7)
Have you ever been arrested?
Yes
No
If "yes" please explain:
Date of Arrest
City of Arrest
State of Arrest
Disposition/Penalty
Charge
2. Do you have a clean driving record?
Yes
No
If "no" please explain:
3. Have you been previously employed at Achieve?
Yes
No
If "yes" indicate site and reason for leaving:
4. Are you related to anyone at Achieve?
Yes
No
If "yes" indicate name & relationship:
5. Have you previously applied to Achieve?
Yes
No
If "yes" please indicate:
Location
Position
Date
6. Are you at least 18 years of age?
Yes
No
If no, parent, guardian must mail letter of consent or drop off at: Achieve Builds Confidence, Inc 3079 W. Ina, Tucson, AZ 85741 520-597-8824
7. How did you hear about Achieve?
Record of Education
High School Name
City
State
Course of Study
Years Completed
Did you graduate?
Yes
No
Last Diploma/Degree
College Name
City
State
Course of Study
Years Completed
Did you graduate?
Yes
No
Last Diploma/Degree
Graduate School
City
State
Course of Study
Years Completed
Did you graduate?
Yes
No
Last Diploma/Degree
Other Qualifications
courses taken, special skills, certifications, training, software skills, seminars, attended, etc.
Employment History
Present or Last Employer
Telephone Number
Address
City
State
Start Date
End Date
Starting Salary
Bonus
Final Salary
Bonus
Job Responsibilities
Are you currently employed here?
Please select
Yes
No
If no, please state reason for leaving:
If employer listed above is your present employer, may he or she be contacted?
Please select
Yes
No
Past Employers
Employer 1
Employer's Name
Phone Number
Address
City
State
Starting Date
Ending Date
Starting Salary
Bonus
Ending Salary
Bonus
Are you currently employed here?
Please select
Yes
No
If no, please state reason for leaving:
Employer 1
Employer's Name
Phone Number
Address
City
State
Starting Date
Ending Date
Starting Salary
Bonus
Ending Salary
Bonus
Are you currently employed here?
Please select
Yes
No
If no, please state reason for leaving:
Questionnaire
What is your experience, if any, working with adults with disabilities?
Considering your work history, what was your favorite job?
What did you like more about your favorite job? What did you like least?
What do you feel are your strengths?
How do you feel about taking people who may have negative behaviors (i.e. toileting accidents, tantrums, self-abuse) out in public setting?
If an accident occurs with a participant while you are out in the community what would you do?
What would you do if you had a concern about a participant's personal care?
If you noticed a participant assigned to another staff, was being unproductive, what would you do?
What are your feelings regarding staff disagreements, and how do you think they should be handled?
How do you feel about taking direction from a peer/colleague
What are your feelings regarding discussion of personal issues during work?
Do you concider yourself organized when it comes to paperwork?
What do you expect from your supervisor?
Brush Teeth?
Please select
Yes
No
Clean Bathrooms?
Please select
Yes
No
Change Diapers?
Please select
Yes
No
Assist people with eating?
Please select
Yes
No
Do Manicures?
Please select
Yes
No
Do you have lifting restrictions?
Please select
Yes
No
Take a drug test?
Please select
Yes
No
Swim?
Please select
Yes
No
Interested in transporting?
Please select
Yes
No
Stay for respite?
Please select
Yes
No
When are you available to start work?
Do you have any planned vacations in the next 3 months? Yes/No. If "yes", add date.
Online Signature
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