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Application for Employment
Personal Information
First Name
Last Name
Middle Initial
Address
City
State
Zip Code
Home #
Cell #
Job Information
Position Applying For
Type of Employment You Are Seekingselect one or more
If Summer, Seasonal, or Part Time: (Optional)
Start Date Available
End Date
Days Availableselect one or more
Questions (1-7)
1.) Have you ever been arrested?
If "yes" please explain:
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Date of Arrest
City of Arrest
State of Arrest
Disposition/Penalty
Charge
2.) Do you have a clean driving record?
If "no" please explain:
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3.) Have you been previously employed at Achieve?
If "yes" indicate site and reason for leaving:
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4.) Are you related to anyone at Achieve?
If yes, please indicate Name & Relationship
5.) Have you ever previously applied to Achieve?
If "Yes" Please indicate:
Location:
Position:
Date
6.) Are you at least 18 years of age?
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?Brief Explaination
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Record of Education
High School Name
City
State
Course of Study
Years Completed
Did you Graduate?
Last Diploma/Degree
College Name
City
State
Course of Study
Years Completed
Did you Graduate?
Last Diploma/Degree
Graduate School
City
State
Course of Study
Years Completed
Did you Graduate?
Last Diploma/Degree
Other Qualificationscourses taken, specials skills, certifications, training, software skills, seminars attended, etc.
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Employment History
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Present or Last EmployerCompany's Name
Telephone Number
Address
City
State
1.) Starting Datemm/dd/yyyy
2.) Ending Datemm/dd/yyyy
Starting Salary
Final Salary
Bonus(if any)
Bonus(if any)
Job ResponsibilitiesList your job responsibilities here
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Are you currently employed here?
If no, please state reason for leaving:
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If employer listed above is your present employer, may he or she be contacted?
Past Employers
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Employer 1
Employer's Name
Telephone
Address
City
State
1.) Starting Datemm/dd/yyyy
2.) Ending Datemm/dd/yyyy
Starting Salary
Ending Salary
Bonus(if any)
Bonus(if any)
Are you currently employed here?
If no, please state reason for leaving:
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Employer 2
Employer's Name
Telephone
Address
City
State
1.) Starting Datemm/dd/yyyy
2.) Ending Datemm/dd/yyyy
Starting Salary
Ending Salary
Bonus(if any)
Bonus(if any)
Are you currently employed here?
If no, please state reason for leaving:
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Employer 3
Employer's Name
Telephone
Address
City
State
1.) Starting Datemm/dd/yyyy
2.) Ending Datemm/dd/yyyy
Starting Salary
Ending Salary
Bonus(if any)
Bonus(if any)
Are you currently employed here?
If no, please state reason for leaving:
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Questionnaire
1. What is your experience, if any, working with adults with disabilities?
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2. Considering your work history, what was your favorite job?
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3. What did you like most about your favorite job? What did you like least?
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4. What do you feel are your strengths?
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5. How do you feel about taking people who may have negative behaviors (i.e. toileting accidents, tantrums, self-abuse) out in a public setting?
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6. If an incident occurs with a participant while you are out in the community what would you do?
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7. What would you do if you had a concern about a participant’s personal care?
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8. If you noticed a participant assigned to another staff, was being unproductive, what would you do?
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9. What are your feelings regarding staff disagreements, and how do you think they should handled?
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10. How do you feel about taking direction from a peer/colleague?
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11. What are your feelings regarding discussion of personal issues during work?
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12. Do you consider yourself organized when it comes to paperwork?
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13. What do you expect from your supervisor?
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Brush Teeth?
Clean Bathrooms?
Change Diapers?
Assist people with eating?
Do Manicures?
Do you have lifting restrictions?
Take a drug test?
Swim?
Interested in transporting?
Stay for respite?
15. When are you available to start work?
16. Do you have any planned vacations in the next 3 months? Yes / No. If “yes”, add date
Online Signature
Add some text or HTML here
Check this box to agree to the above statement.
Type Full Name
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