Job Application

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Email: Enter Email

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Address: Enter Address

City: Enter City

State: Enter State

Zip Code: Enter Zip Code

Phone: Enter Phone

Cell Phone: (Optional) Enter Cell Phone

Do you have your own transportation?

Yes

Do you have a valid Driver's license?

Yes

License #: Enter License #

Have you ever been convicted of a felony?

Yes

If Yes please explain: Enter Explanation

Are you a US citizen?

Yes

If No, do you have an alien registration card work permit?

Yes

Are you comfortable working with people who are non-verbal?

Yes

What types of Personal Care issues are you comfortable working with? Enter Your Message

Do you have any First Aid/CPR training?

Yes

Do you smoke?

Yes

Can you lift or transfer?

Yes

Up to how many lbs? Enter Text

When are you able to work? Please check all that apply.

Full time

Part time

Days

Evenings

Overnights

Weekdays

Weekends

Name of High School: Enter Text

Dates Attended: Enter Text

Highest grade completed: Enter Text

Name of College: Enter Text

Dates attended: Enter Text

Highest grade completed: Enter Text

Major: Enter Text

Are you currently in school?

Yes

If yes will your hours need to change regarding school schedule?

Yes

Job Title or Type of work: Enter Title

Employer and Name of Supervisor: Enter Employer and Supervisor

Dates of employment: Enter Begin and End Date

May we contact: (phone number) Enter Phone Number

Job Title or Type of work: Enter Title

Employer and Name of Supervisor: Enter Employer and Supervisor

Dates of employment: Enter Begin and End Date

May we contact: (phone number) Enter Phone Number

Name: Enter Name

Relationship: (How Long) Enter Relationship

Address: Enter Address

Phone #: Enter Phone

Name: Enter Name

Relationship: Enter Relationship

Address: Enter Address

Phone #: Enter Phone

Please list some of your strengths, training needs, and preferences for working with individuals here. Enter Your Message

Any additional comments: Enter Your Message

More Work Experience

By sending this you hereby certify that the information you have provided is true and accurate to the best of your knowledge. Please be aware that if an investigation reveals any false statements or information, you will no longer be considered for employment.

Phone 785-820-8018

Fax 785-309-0438

Choices Network Inc.

2151 Centennial Rd.

PO Box 2657

Salina, KS 67402-2657