Online Application

Your Employment ...

Referral Source:

Choose: Source Name:

Position Applying For:

Desired Position: Date Available:

Type of Employment Desired: Full-Time Part-Time Relief/Subbing Any

Type of Shift Desired: First Second Third Any

Distance Willing To Travel:

Can you assist someone from wheelchair into an alternate position? Yes No

Are you a citizen of the United States? - Are you authorized to work in the U.S.?Yes No	Yes	No
Have you ever applied / interviewed with this agency before? - When did you apply?	Yes	No
Have you ever worked for this agency before? - When did you leave?	Yes	No

Your Educational Background ...

Education:

Institution	Name/Location of School	Years Attended	Degree(s)
High School		to Graduated? Yes No
College		to Graduated? Yes No
Other Training / Certificates		to Graduated? Yes No

Volunteer Experience:

Your Professional Background ...

Employment History:

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

Current or Latest Employer #1:

Company:

Phone:

Address:

Supervisor:

Job Title:

Employed From:

to

Responsibilities:

Reason for Leaving:

May we contact your supervisor for a reference?Yes No

Previous Employer #2:

Company:

Phone:

Address:

Supervisor:

Job Title:

Employed From:

to

Responsibilities:

Reason for Leaving:

May we contact your supervisor for a reference?Yes No

Previous Employer #3:

Company:

Phone:

Address:

Supervisor:

Job Title:

Employed From:

to

Responsibilities:

Reason for Leaving:

May we contact your supervisor for a reference?Yes No

Professional References:

1.	Name:		Years Acquainted:
1.	Company and Title:		Business Phone:

2.	Name:		Years Acquainted:
2.	Company and Title:		Business Phone:

Legalities ...

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?

Yes No

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:

- September 4, 2010

Are You Over 18 years of age?	Yes	No
Do you have a high school diploma or a GED?	Yes	No
Do you have a valid driver’s license?	Yes	No
Have you been driving for at least two years?	Yes	No