Assisted Services - Join Our Team

Employee Application

General Information (* required)

First Name*:	Middle Initial:
Last Name*:
Address*:	City*:
State*:	Zip:
Phone 1*:	Phone 2:
Email*:
Are you a U.S. citizen or authorized by INS to work?* Yes No
Have you ever been convicted of any crime?** Yes No

Position Information
Position inquiring about (check all that apply):
	Homemaker/Companion PCA CNA HHA LPN RN Other:
Location desired:
	Lawrence Topeka Leavenworth Wyandotte County Johnson County
Availability:	Full time Part Time
How many hours per week do you want to work?:
	Flexible 0-10 10-20 20-30 30-40 40+
How many days per week do you want to work?:
	Flexible 1 2 3 4 5 6 7
What days are you available to work?:
	Flexible Monday Tuesday Wednesday Thursday Friday Saturday Sunday
What time are you available to start each day?:
	Flexible Before 6am 6-8am After 8am After 12pm
How late are you available to work each day?:
	Flexible 3pm-5pm 5pm-7pm After 7pm After 8pm

Education
High School:		Completed
College:	Course of Study:	Completed
Trade/Other:	Course of Study:	Completed

Employment History (Start with most recent employer)
Company 1	Employed (MM/YY to MM/YY)
Address:	Phone:
Position	Leaving Salary
Company 2	Employed (MM/YY to MM/YY)
Address:	Phone:
Position	Leaving Salary
Company 3	Employed (MM/YY to MM/YY)
Address:	Phone:
Position	Leaving Salary

References
Name, Occupation, Years Known
Relationship: Supervisor Co-worker Friend Other
Name, Occupation, Years Known
Relationship: Supervisor Co-worker Friend Other

In addition to your work history, are there any other skills, qualifications, or experience that we should consider?


* Documentaion may be required
**This will not necessarily affect your application