Seniors Helping Seniors Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

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Zip *

Driver's License Number

-- AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI AA AE AP MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UM UT VT VI VA WA WV WI WY AB BC MB NB NL NT NS NU ON PE QC SK YT

Section 1 - FORMS COMPLETED

Signed Addendum to Service Agreement

  Yes   No

Signed Job Description

  Yes   No

Section 2 - General Information

Date Available? (required)

 

Effective Date *

Job Type? (required)

-- Select an Option -- Full Time Part Time? Set Schedule On Call Any

Can you provide documentation of a driver's license and auto insurance? (required)

  Yes   No

Drivers License Expiration Date: (required)

 

Expiration Date *

Auto Insurance Expiration Date: (required)

 

Effective Date *

Expiration Date *

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)

  Yes   No

If yes, please explain.

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Section 3 - Employment Verification

Are you a U.S. citizen? (required)

  Yes   No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

-- Select an Option -- I am authorized to work in the U.S. for any employer. I am authorized to work in the U.S. only for my current employer. I require sponsorship to work in the U.S. I do not know my work status.

Section 4 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

  Yes   No

Years Attended (From/To): (required)

Additional Education (vocational, undergraduate, etc.)

  Yes   No

If yes, please list the name of the school and years attended (From/To)

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Section 5 - Other Training: Certifications/Licenses

Certifications/Licenses:

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Section 6 - Current Employment

Current Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

-- Select an Option -- Full Time Part Time Temporary

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

  Yes   No

Section 7 - Employment History

Last Employer: (required)

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

-- Select an Option -- Full Time Part Time Temporary

Position/Title: (required)

Describe Your Responsibilities: (required)

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Supervisor's Name/Title: (required)

Supervisor's Phone: (required)

Reason for Leaving: (required)

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May we contact? (required)

  Yes   No

Section 9 - Reference 1

Name: (required)

Relationship (required)

Phone: (required)

Section 10 - Reference 2

Name: (required)

Relationship (required)

Phone: (required)

Section 11 - Reference 3

Name: (required)

Relationship (required)

Phone: (required)