Salutation: Mr. Mrs. Ms. Other


First Name:

Last Name:

Street Address:

City:

State:

Zip Code:


Cross Streets:

E-mail:


Phone Number:




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Age Range: (Must be at least 18 to apply.) 18 - 20 21+
Do you have a valid driver's license? yes no
Driver's License State:
Your means of transportation:
I have my own vehicle.
I share a vehicle.
I depend on others for a ride.
I use public transportation.
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I currently hold the following certifications: (check all that apply)

Article 9
CPR
First Aid
Prevention and Support
Habilitation

DCW Principles of Caregiving Level 1 - Fundamentals
DCW Principles of Caregiving Level 2 - Developmental Disabilities
DCW Principles of Caregiving Level 2 - Aging and Physical Disabilities
Positive Behavior Support
Other
Please list both professional and personal experiences. Both count and will be taken into consideration.
I have the following experience in working with individuals with developmental disabilities:

I have the following experience in working with children:

I have the following experience in providing personal care to individuals:

I have the following experience in teaching, coaching, training, etc:

I have the following experience in tracking/documenting results:

Other relavent experience that should be considered:

What languages do you speak?

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What sort of client are you willing to work with?

What sort of client are you not willing to work with?

When are you available to work? (weekdays, weekends, holidays, over-nights)

How many hours per week do you want to work?
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List your last three jobs, starting with the most recent. Please tell us about your job duties, when you began, when you left, and why you left.
Job 1: From: To: Salary:

Job 2: From: To: Salary:

Job 3: From: To: Salary:

What salary do you expect to make with Imagine Support Services, LLC?

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How did you learn about this employment opportunity?
Craig's List
Indeed.com
Friend or Family Memeber.
Flyer or Job Fair
Other Website

Do you already have a client? No Yes

Is there anything else that you would like us to take into consideration?