Independent Living Center of Northeast Kansas, Inc.

 

APPLICATION FOR

PERSONAL CARE ATTENDANT

ÞThe Independent Living Center, as required by law, does not discriminate against any person on the basis of  race, color, religion, national origin, ancestry, age, disability or sex in any employment transaction.

 

EMPLOYEE DATA:                                                             DATE:_________________ 

 

Name: ______________________________________________SS#______________________

 

Address:____________________________________________City:______________________

 

State:____________  Zip Code: __________________Phone:____________________________

 

Alternate Phone Number:___________________________________

 

1.  Are you prevented from becoming lawfully employed in this country because of visa or immigration status?   ○ Yes               ○ No

 

2.  Have you been employed as a Personal Care Attendant with this Agency as Payroll

Agent?   ○ Yes ○  No               If yes, When?_______________________

 

3.  Do you have your own means of transportation to the individual’s home and/or take the individual you will be working with for shopping?  ○ Yes                     ○ No

 

4.  Have you been convicted of a felony within the past seven years?  ○ Yes      ○  No

            (conviction will not necessarily disqualify applicants from employment)

 

5.  On what date could you begin work?  ______________________________

 

AREA(S) WHICH YOU ARE WILLING TO WORK:

Specific Town(s) or areas:  _______________________________________________________

 

EDUCATION:

            High School Graduate or GED?  [  ]  Yes         [  ]  No

 

PERSONAL REFERENCES (NOT FORMER EMPLOYERS OR RELATIVES):

Name & Occupation                                        Address                                               Phone  

 

______________________________________________________________________________

______________________________________________________________________________

 

______________________________________________________________________________

 

CHECK DAYS AND TIMES YOU ARE AVAILABLE/WILLING TO WORK:

○Sunday ○Monday  ○Tuesday  ○Wednesday  ○Thursday  ○Friday  ○Saturday

○7am to 12 noon  ○12 noon to 5 pm    ○  5 pm to 10 pm ○ 10 pm to 7am

 

PERSONAL CARE EXPERIENCE (DESCRIPTION & DURATION)

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

EMPLOYMENT EXPERIENCE:

Begin with present or last employer.  Include military service assignments and volunteer activities.  Do not include organization names indicating race, sex, or national origin.

 

____________________________________________________      _______________________

Employer’s Name and Address                                                                        Telephone

 

__________________________________________________ From__________ To__________

Your Job Title                                                                             

                                                                                                       Salary: $__________ per______

___________________________________________                 Part-time______ Full time_____

Supervisor

____________________________________________________      _______________________

Employer’s Name and Address                                                                        Telephone

 

__________________________________________________ From__________ To__________

Your Job Title                                                                             

                                                                                                       Salary: $__________ per______

___________________________________________                 Part-time______ Full time_____

Supervisor

____________________________________________________      _______________________

Employer’s Name and Address                                                                        Telephone

 

__________________________________________________ From__________ To__________

Your Job Title                                                                             

                                                                                                       Salary: $__________ per______

___________________________________________                 Part-time______ Full time_____

Supervisor

CHECK ALL THE PERSONAL CARE SERVICES YOU ARE WILLING TO PERFORM:

○ Transferring   ○ Plan Meals                ○ Transportation           ○ Bathing/Showering

○ Shopping      ○ Cooking                    ○ Personal Hygiene      ○ Recreational Activities

○ Medication    ○ Toileting                    ○ Feeding                     ○ Laundry

○ Grooming      ○ Cleaning                    ○ Dressing                    ○ Housekeeping