ApplyEast

Postion Applying For		Date
First Name		Last Name

Street Address

City

State

Zip

Primary Phone Number

Secondary Phone Number

Email Address (Required)

18 years or older?	Yes No
Have you previously applied at Full Life?	Yes No
Do you have a valid driver's license?	Yes No
Do you have reliable transportation?	Yes No

If yes, when?

	Employment History: Starting with present or most recent, list your last 3 previous employers. Include self-employment, military service, summer, and part-time jobs.

Most recent or current employer	Postion Title	Supervisor Name

Employer Phone	Dates employed (from - to)	Wage or salary per hour

Reason for Leaving?

Previous employer	Postion Title	Supervisor Name

Employer Phone	Dates employed (from - to)	Wage or salary per hour

Reason for Leaving?

Previous employer	Postion Title	Supervisor Name

Employer Phone	Dates employed (from - to)	Wage or salary per hour

Reason for Leaving?

	References (not relatives and at least 2 business references)

Name	Occupation

Phone Number	City or Town

Name	Occupation

Phone Number	City or town

Name	Occupation

Phone Number	City or town

EDUCATION
Name of High School	City and State

Did you graduate?	YES NO

Name of Institution	City and State

Years Attended	Course of Study

Degree or Certificate Earned:

Name of Institution	City and State

Years Attended	Course of Study

Degree or Certificate Earned:

Name of Institution	City and State

Years Attended	Course of Study

Degree or Certificate Earned:

Sign Language	YES NO
One year experience working with people with disabilities?	YES NO
Mandt Training?	YES NO
CPR Certificate?	YES NO
First Aid Certificate?	YES NO
CNA Certificate?	YES NO
Positive Behavioral Supports Training?	YES NO
Certified Direct Support Worker or Caregiver?	YES NO

Skills and Certificates

	Please describe other job related training, scholastic honors, and vocational and/or professional information:

What type of position are you looking for?
Full Time
Part Time
Temporary
Internship
On-Call

When are you available?
Early Morning
Daytime
Afternoons
Evenings
Overnight
Weekends

How many hours a week?

	Please explain your availability if we need more information:

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 accident
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?
6. If there is the possibility that someone may bite you?
7. If the individual you are assisting exhibits inappropriate sexual behavior?
8. If someone yells or uses profanity?
Are you willing (and able) to assist individuals who have physical challenges by:	YES	NO
9. Lifting and/or assisting individuals that are non ambulatory
10. Learn to use mechanical devices to assist individual
Are you willing to help individuals be a part of their community and to:	YES	NO
11. Accompany individuals to community activities and events
12. Assist individuals in utilizing public transportation
13. Use your personal automobile to transport our clients?
Are you willing and able to be a part of the team and agree that you will:	YES	NO
14. Be dependable and show up for work on time as scheduled
16. Work occasionally for others when they are unable to work
17. Work some holidays
18. Participate in required training within the specified time lines

Do you currently know anyone working for Full Life?

YES NO

If yes, who?

Full Life is an equal opportunity employer. Full Life will not discriminate on the basis of race, color, gender, gender orientation, national origin, veteran status or disability. Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application process and/or interview process should notify the Human Resources Assistant at 322-9333.

There are terms and conditions to employment at Full Life that will be covered if you are offered a position. You should know that by clicking on the submit button at the bottom of this page, you acknowledge that any misrepresentation on this application may be justification for refusal to interview or termination from employment, if hired. You also agree that we may verify all data entered on this application and you release Full Life and any person giving or receiving such information from liability.

I agree to the terms above and indicate so by typing my initials in the box.


			Click submit to apply for a position in East Hawai'i.