ABIL ABIL
Arizona Bridge to Independent Living PERSONAL ASSISTANT SERVICES
1229 E Washington St.
Phoenix, Arizona 85034-1101 QUESTIONNAIRE
(602) 256-2245
Date:
___________________PERSONAL
INFORMATION________________________
Legal Name:
Street
Address:
Mailing Address: Apt
#:
City: State: Zip:
Cross
Streets:
How
long at above address:
Previous
Address: How
Long?
(* Optional)
Home Phone: ( ) * Social Security#:
Work Phone: ( )
* Date of Birth:
Are you applying for the training
to care for a specific person? Yes No
If
yes, Name: Relationship:
How did you learn of ABIL’s
Personal Assistant Services Program?
Maricopa
County Long Term Care ____ ABIL
Trained Attendant ____
Rehabilitative Agency or Program
____ Newspaper
Ad ____ Other ____
_______________________________________________________________________________________________________
Salary Expected
$ _________/ Hour
_______________________________________________________________________________________________________
Who should we notify during
the training, in case of an emergency:
Name: Relationship:
Home Phone: Business Phone:
______________________________________________________________________________________________
Is there a reasonable
accommodation that could be made to enable you to perform the essential
functions
of
this a job?
Have you ever been convicted of a felony or
misdemeanor, including sex-related or child abuse related offenses?
Yes No If yes, please explain:
May we have permission to contact your probation officer? Yes No
Name of probation officer: Phone #:
___________________________________________________________________________________________
Please answer the following questions:
1. What do you feel are your qualities for being a Personal Assistant?
__
__
__
2. Why do you want to work as a Personal Assistant?
__
__
__
3. What services do you see yourself providing as a Personal Assistant?
__
__
______________________________________________________________________________________________
__________EDUCATION
& TRAINING___________
High School: Year Graduated/GED:
College: Location (City/State): Year Graduated: Phone: ( )
College: Location(City/State): Year Graduated: Phone:
ABIL reserves the right to verify education.
Please describe any other
training you have completed:
__
__
Please indicate any foreign languages spoken fluently:
__
______________________________________________________________________________________________
___________________________WORK HISTORY___________________________________
Carefully fill in the
information below. Volunteer experience may be substituted if there is no
employment history. In order to process your application, you must provide
complete names and addresses of your employers. Without this information your
application cannot be processed. (Please list most recent
employment first)
Name of Employer: Supervisor:
Address:
Dates of Employment:
City: State: Zip: Telephone:
Name of Employer: Supervisor:
Address:
Dates of Employment:
City: State: Zip: Telephone:
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Name of Employer: Supervisor:
Address:
Dates of Employment:
City: State: Zip: Telephone:
______________________________________________________________________________________________
_________Personal
References __________
Carefully fill out the information below. In order to process your application you must provide the complete names and addresses of two personal references. These are people who are not relatives and whom you have known at least one year.
Name: Relationship:
Address: Length of Acquaintance:
City: State: Zip: Telephone:
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Name: Relationship:
Address: Length of Acquaintance:
City: State: Zip: Telephone:
_______________________________________________________________________________________________________
I hereby state the above information is correct to the best of my knowledge and authorize investigation and verification of all statements contained in this application. I understand that misrepresentation or omission of facts may render me ineligible for consideration.
SIGNATURE : DATE:
FOR OFFICE
USE ONLY:
Accepted: ______________ Denied: ______________ Other: _______________
Date: _______________________________
Remarks: ______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________