Personal Assistant Application I understand that my application will not be accepted until I pay the background check fee. YESNO Personal Data Date Last Worked Date of Birth Have you ever been convicted of a felony? YESNO If yes, please explain: What services do you feel you will need as you seek work? What are your career goals? (type of job you are seeking) Salary Expections: Total hours available per week: I would like to work: (choose all that apply) Full TimePart TimeTemporaryContract Does your disability limit the type of work you can do? YESNO If yes, please explain: What is your disability and how does it limit your ability to work? Monthly amount of your Social Security Benefit: • SSDI • SSI Other sources of income: • Long Term Disability • Workman's Comp • Other Do you have a valid Driver's License? YESNO Do you have a working vehicle? YESNO If no, how will you get to work? High level of education: GED, High School DiplomaSome CollegeAssociates DegreeBachelors DegreeMaster's DegreeDoctorateOther Field of special training or college degree: Employment History If you have ever been terminated from a position, please explain In the space provided, please list the last 3 positions you held. Additionally, you may send your resume if you have one. Employer Name Position / Job Title From To Responsibilities Reason for leaving Employer Name Position / Job Title From To Responsibilities Reason for leaving Employer Name Position / Job Title From To Responsibilities Reason for leaving Please explain any gaps in your work history Additional comments Thank you for completing the Employment Services Application. Please review your answers. Once you are comfortable with your answers, hit submit to send the application.