Position Applying for:
Your First Name:            Middle   Last Name     
Mailing Address                                  City                      State    Zip   
Physical Address                                 City                      State    Zip   
Primary Phone #:
 Secondary Phone #:
Email Address:
If you do not currently have an email address, would you be willing to
get one for this job?
Yes
No
Are you 18 or over?
 Yes
No
If no, do you have a work permit?
 Yes
 No
Yes
 No
Have you previously applied at Full Life?
If yes, when?
Yes
 No
Do you have a valid driver's license?
Employment History: Starting with present or most recent, list your last 3 previous
employers. Include self-employment, military service, summer, and part-time jobs.
Current or most recent employer:
 Position Title:
 Supervisor Name:
Employer Address                                City                        State    Zip
Employer Phone:          Dates Employed                          Wage or Salary
Per
Reason for
Leaving:
Previous employer:
 Position Title:
 Supervisor Name:
Employer Address                                City                        State    Zip
Employer Phone:          Dates Employed                          Wage or Salary
Per
Reason for
Leaving:
Previous employer:
 Position Title:
 Supervisor Name:
Employer Address                                City                        State    Zip
Employer Phone:          Dates Employed                          Wage or Salary
Per
Reason for
Leaving:
References (not relatives and at least 2 business references)
1



2



3
Education:
Yes
Graduated?
 No
Yes
Graduated?
 No
Yes
Graduated?
 No
Yes
Graduated?
 No
Indicate the skills or certification listed below:
(to select more than one, hold down the control key while clicking on your selections)
Please list other job related training, scholastic honors, and vocational and/or
professional information:
What type of
position would
you prefer?
When are you available?
 How many hours per
week are you
interested in?
Full Time
Part Time
Temporary
Summer
Internship
On-Call
Early Mornings: 6 a.m - 9 a.m.
Daytime: 9 a.m. - 6 p.m.
Afternoon: 2 p.m. - 6 p.m.
Evenings: 2 p.m. - 10 p.m.
Overnights
Weekends
Are you willing to provide personal assistance to individuals
such as:
 YES
 NO
1. Helping individuals who are unable to toilet themselves
2. Changing Attends and cleaning after toileting accidents
3. Helping individuals who are unable to bathe themselves
4. Helping individuals who are unable to feed themselves
Are you willing to assist individuals that have behavioral
challenges if:
 YES
 NO
5. There is a possibility that an individual may hit or kick you?