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:

    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.