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Application for Employment

Personal Information

First Name

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Middle Initial

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Last Name

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Address

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City

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State

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Zip Code

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Home #

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Cell #

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Emaila valid email

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Job Information

Position Applying For

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Type of Employment You Are Seekingselect one or more

RegularSummer/SeasonalPart TimeTemporaryFull Time 35+ hrs

If Summer, Seasonal, or Part Time: (Optional)

Start Date Available

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End Date

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Days Availableselect one or more

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Questions (1-7)

1.) Have you ever been arrested?

YesNo

If "yes" please explain:

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Date of Arrest

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City of Arrest

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State of Arrest

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Disposition/Penalty

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Charge

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2.) Do you have a clean driving record?

YesNo

If "no" please explain:

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3.) Have you been previously employed at Achieve?

YesNo

If "yes" indicate site and reason for leaving:

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4.) Are you related to anyone at Achieve?

YesNo

If yes, please indicate Name & Relationship

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5.) Have you ever previously applied to Achieve?

YesNo

If "Yes" Please indicate:

Location:

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Position:

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Date

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6.) Are you at least 18 years of age?

YesNo

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

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City

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State

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Course of Study

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Years Completed

Select An Option1234

Did you Graduate?

Select An OptionYesNo

Last Diploma/Degree

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College Name

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City

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State

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Course of Study

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Years Completed

Select An Option1234

Did you Graduate?

Select An OptionYesNo

Last Diploma/Degree

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Graduate School

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City

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State

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Course of Study

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Years Completed

Select An Option1234

Did you Graduate?

Select An OptionYesNo

Last Diploma/Degree

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Other Qualificationscourses taken, specials skills, certifications, training, software skills, seminars attended, etc.

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Employment History

Add some text or HTML here

Present or Last EmployerCompany's Name

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Telephone Number

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Address

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City

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State

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

1.) Starting Datemm/dd/yyyy

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2.) Ending Datemm/dd/yyyy

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Starting Salary

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Final Salary

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Bonus(if any)

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Bonus(if any)

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Job ResponsibilitiesList your job responsibilities here

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Are you currently employed here?

Select An OptionYesNo

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?

Select An OptionYesNo

Past Employers

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Employer 1

Employer's Name

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Telephone

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Address

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City

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State

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

1.) Starting Datemm/dd/yyyy

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2.) Ending Datemm/dd/yyyy

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Starting Salary

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Ending Salary

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Bonus(if any)

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Bonus(if any)

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Are you currently employed here?

Select An OptionYesNo

If no, please state reason for leaving:

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Employer 2

Employer's Name

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Telephone

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Address

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City

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State

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

1.) Starting Datemm/dd/yyyy

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2.) Ending Datemm/dd/yyyy

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Starting Salary

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Ending Salary

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Bonus(if any)

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Bonus(if any)

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Are you currently employed here?

Select An OptionYesNo

If no, please state reason for leaving:

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Employer 3

Employer's Name

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Telephone

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Address

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City

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State

Select An OptionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

1.) Starting Datemm/dd/yyyy

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2.) Ending Datemm/dd/yyyy

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Starting Salary

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Ending Salary

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Bonus(if any)

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Bonus(if any)

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Are you currently employed here?

Select An OptionYesNo

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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Add some text or HTML here

Brush Teeth?

YesNo

Clean Bathrooms?

YesNo

Change Diapers?

YesNo

Assist people with eating?

YesNo

Do Manicures?

YesNo

Do you have lifting restrictions?

YesNo

Take a drug test?

YesNo

Swim?

YesNo

Interested in transporting?

YesNo

Stay for respite?

YesNo

15. When are you available to start work?

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16. Do you have any planned vacations in the next 3 months? Yes / No. If “yes”, add date

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Online Signature

Add some text or HTML here

Check this box to agree to the above statement.

I agree

Type Full Name

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Submit Application

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