Personal Care Assistant Services Application

Thank you for your interest in joining ABIL as one of our exceptional Personal Care Assistants.

While completing the employment application below, please make every effort to fully and clearly answer all questions.

* You are required to answer fields with an asterisk (*).

Date: *

Location Applying For: *

Personal Information

Legal Name: *

Other Names Used (AKA); if none, put "none": *

Street Address: *

Mailing Address:

City: *

State: *

Zip: *

Cross Streets:

How long at above address?:

Previous Address:

How Long?:

Home Phone: *

Email Address (if none, put "None"): *

Work Phone:

4. Who should we notify during the training in case of an emergency?

Name: *

Relationship:

Home Phone: *

Business Phone:

Personal History

Some of the consumers served through ABIL's Personal Assistance Services Program need to be lifted and transferred to and from a wheelchair, bed, toilet or shower bench. Light housekeeping is almost always required including changing linens, doing laundry, preparing meals, vacuuming and dusting. Therefore, applicants for this position may need to perform these functions. If you have any lifting, bending, stooping, twisting, gripping or other physical limitations that may affect your ability to perform these functions, please describe them below. Please note that any limitations you describe will not automatically prevent us from hiring you, and ABIL will make reasonable accommodations to help you do this job if you are hired.

5. I have the following limitations:

Legal Questions

You will be required to complete a Criminal Self-Disclosure Form

6. Have you ever been or are you currently excluded from participating in Medicare, Medicaid, or any other federally-funded health care program?: *

YES

7. Have you ever been convicted of a felony or misdemeanor, including sex related or child/adult abuse related offenses?: *

If Yes, Please Explain:

8. Do you have a probation officer?:

YES

9. May we have permission to contact your probation officer?:

YES

Name of probation officer:

Phone Number:

About You

Please answer the following questions:

10. What qualities do you have that would make you a successful Personal Assistant?:

11. Why do you want to work as a Personal Assistant? :

12. What services do you see yourself providing as a Personal Assistant?:

Education & Training

ABIL reserves the right to verify education.

13. High School:

Year Graduated/GED:

14. College:

Year Graduated:

Phone Number:

College:

Year Graduated:

Phone Number:

15. Please describe any other training you have completed:

16. 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).

Employer 1

Name of Employer:

Supervisor:

Address:

Dates of Employment:

City:

State:

Zip:

Phone Number:

Employer 2

Name of Employer:

Supervisor:

Address:

Dates of Employment:

City:

State:

Zip:

Phone Number:

Employer 3

Name of Employer:

Supervisor:

Address:

Dates of Employment:

City:

State:

Zip:

Phone Number:

Personal References

Carefully fill out the information below. In order to process your application you must provide the complete names and addresses of three personal references. These are people who are NOT relatives and who you have known at least one year.

Reference 1

Name:

Relationship:

Address:

Length of Acquaintance:

City:

State:

Zip:

Phone Number:

Reference 2

Name:

Relationship:

Address:

Length of Acquaintance:

City:

State:

Zip:

Phone Number:

Reference 3

Name:

Relationship:

Address:

Length of Acquaintance:

City:

State:

Zip:

Phone Number:

Signature

ABIL will not discriminate against any employee or applicant on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual preference, or any other protected status under Title VII of the Civil Rights Act of 1964, as amended, the Age Discrimination and Employment Act, State Executive Order No. 75-5, the Rehabilitation Act of 1973, as amended, and the Americans with Disabilities Act.

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.

Help ABIL continue its goal of independent living for people with disabilities.

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Virginia G. Piper
Sports & Fitness
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Disability
Empowerment
Center

Personal Care Assistant Services Application

Help ABIL continue its goal of independent living for people with disabilities.

Send this site to a friend

Follow us on

Text Resize

Meeting SpaceInformation

Virginia G. PiperSports & FitnessCenter

DisabilityEmpowermentCenter

Meeting Space
Information

Virginia G. Piper
Sports & Fitness
Center

Disability
Empowerment
Center