Apply Online

Thank you for applying to West Bay Residential Services! Please fill out all fields, and a representative will contact you!

* Required Fields

Your Information

Last Name * First Name * Middle Initial

Street * City * State * Zip Code *

Phone - Daytime Phone - Evening Phone - Mobile

Email Address *

Eligibility

Are you over 18 years of age? * YesNo

Do you have a high school diploma or a GED? * YesNo

Do you have a valid driver's license? * YesNo

Have you been driving for at least two years? * YesNo

Your Employment Desired Position Type of Employment Desired Type of Shift Desired Distance Willing to Travel Date Available *

Can you assist someone from wheelchair into an alternate position? Are you a citizen of the United States? *

Are you a authorized to work in the United States? *

Have you ever applied / interviewed with this agency before? * Have you ever worked for this agency before? *

When did you apply? /

Employed from: / to /

Referral Source Source Name

Educational Background

Institution	Name/Location of School	Years Attended	Degree(s)
High School		to Graduated? YesNo
College		to Graduated? YesNo
Other Training/Certificates		to Graduated? YesNo

Volunteer Experience *

Your Employment Background

Please provide information pertaining to 3 most previous employers, beginning with the most current or latest employer.

Current or Latest Employer

Company Phone Address Job Title Supervisor

Employed from / to /

Responsibilities Reason for Leaving

May we contact your supervisor for a reference? YesNo

Previous Employer 1

Company Phone Address Job Title Supervisor

Employed from / to /

Responsibilities Reason for Leaving

May we contact your supervisor for a reference? YesNo

Previous Employer 2

Company Phone Address Job Title Supervisor

Employed from / to /

Responsibilities Reason for Leaving

May we contact your supervisor for a reference? YesNo

Professional References

Reference #1

Reference Name Years Acquainted Company Title Business Phone

Additional Reference

Reference Name Years Acquainted Company Title Business Phone

Legal Notice

Rhode Island law requires the following disclosure: *

Have you ever been convicted for any State or Federal Crime as defined by RI Criminal Code or the Federal Code? *

Charges *

Date of Conviction *

Sentence Imposed *

Disclaimer and e-Signature

Please read and check the following: *

Upon hiring, I authorize West Bay Residential Services, Inc. to use my photograph on its website and in other publications. *

I understand that falsification of information contained herein can result in termination of employment at any time after hiring. *

Applicant Signature * May 20, 2012