Whole Life Services, Inc. Application for Employment
Whole Life Services, Inc. is committed to a policy of Equal Employment Opportunity and will not discriminate on any legal recognized basis, including (but not limited to): race, age, color, religion, sex, marital status, national origin, citizenship, ancestry, non-job-related handicap, disability, or veteran status.
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I. PERSONAL BACKGROUND
Full Name
Current Address
Social Security Number
Email Address
*A Valid & Current email address is required for on-line application submissions only. This email address may be used for additional correspondence from Whole Life Services, Inc.
Home Phone Number
*If this does not apply, please fill in each field with 0's.
Mobile Phone Number
*If this does not apply, please fill in each field with 0's
What position are you applying for?
Direct Supports Professional
Residential Supports Professional
Program Manager
Program Specialist
Internship (non-paid)
Other
Desired Salary
Available Start Date
What is your current employment status?
x
Employed
Self-Employed
Unemployed
Student
May we contact your current Employer?
Yes
No
Have you ever applied to this company before?
Yes
No
When did you last apply?
Are you willing to work overtime?
Yes
No
Are a Minor (under age 18)?
Yes
No
Are you able to produce the age/work certificate necessary to obtain employment?
Yes
No
Upon hire, are you able to submit verification of your legal right to work in the US?
Yes
No
Have you ever been convicted of a Felony?
*This question does not apply to convictions that have been sealed or expunged. A conviction record will not necessarily be a bar
Yes
No
Please fully describe the Felony conviction(s); listing the nature of the offense, your age at the time, and your rehabilitation since the offense(s);
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II. EDUCATIONAL BACKGROUND
Name of High School
Grade Completed
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
High School Address
Graduated?
Yes
No
Major Areas of Study
Name of College or University
Level Completed
< 1 Year
1 Year
2 Years
3 Years
4 Years
Associate's Degree
Bachelor's Degree
Masters Degree
Doctorate
College or University Address
Graduated?
Yes
No
Major Areas of Study
Other Education: Technical School or Other Training/Schooling
Level Completed/Certificate or Degree Earned
Address
Graduated?
Yes
No
Major Areas of Study
Please list any Specialized Technical or Special Skills (IE: Computer Programming, Language, Equipment Operation, Special tools or Machines used):
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III. WORK EXPERIENCE
Please List your last 4 Employers, (starting with your present or last place of employment):
Employer#1 Name
*Give the name of your Current or Most Recent place of employment
Position
Employer#1 Address
Employment Start Date:
Your Current Status with this Employer:
I am currently employed here
I am no-longer employed here
Employment End Date:
Name of Supervisor
Supervisor's Phone Number
Salary
Reason for leaving
Employer#2 Name
*Give the name of your Second Most Recent Employer
Position
Employer#2 Address
Employment Start Date:
Your Current Status with This Employer:
I am currently employed here
I am no-longer employed here
Employment End Date:
Name of Supervisor
Supervisor's Phone Number
Salary
Reason for leaving
Employer#3 Name
*Give the name of your Third Most Recent Employer
Position
Employer#3 Address
Employment Start Date:
Your Current Status with this Employer:
I am currently employed here
I am no-longer employed here
Employment End Date:
Name of Supervisor
Supervisor's Phone Number
Salary
Reason for leaving
Employer#4 Name
*Give the Name of your Fourth Most Recent Employer
Position
Employer#4 Address
Employment Start Date:
Your Current Status with this Employer:
I am currently employed here
I am no-longer employed here
Employment End Date:
Name of Supervisor
Supervisor's Phone Number
Salary
Reason for leaving
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IV. REFERENCES
Give the names of 3 people (not related to you), who can verify your work ethic/capabilities (a supervisor and/or someone you have worked with)
Person#1 First & Last Name
Their Occupation
Person #1 Address
Person#2 Phone Number
Number of Years Known
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Person#2 First & Last Name
Their Occupation
Person#2 Address
Person#2 Phone Number
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Person#3 First & Last Name
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Person#3 Phone Number
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V. APPLICATION QUESTIONS
1. Why are you applying for this position?
2. How would people you have worked with describe you?
3. Describe your ideal work environment or "The Perfect Job"
4. Do people ever come to you for help with solving problems?
Yes
No
Please describe why:
5. Tell us how the quality of your work impacts others around you:
6. People react differently when job demands are constantly changing. How would you react to this?
7. We believe that this organization should work as a Team. what is essential for a team to be successful?
8. How would you react if an Individual that you support (or their family member) told you that they do not like the level of care that you are giving them?
9. What do you do when you feel that someone is not listening to you?
10. What type of events cause you to have stress on the job?
11. 2 X 7=?
12. 5 + 5= ____ + 2=____ ÷ 6=?
13. 1.5 + 3 + .75 + 1.25=?
14. Convert to a Decimal: 3/4=?
15. Convert to a Decimal: 1/4=?
16. $10.00 - $4.75=?
17. $20.00 - $6.89=?
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VI. AVAILABILITY QUESTIONNAIRE
SECTION-A: Are you AVAILABLE to Work during the 3 Shifts listed below? (Check YES or NO):
1. Monday- Friday 9AM-5PM?
Yes
No
2. Weekends?
Yes
No
3. Holidays?
Yes
No
SECTION-B: For each Day of the Week Listed Below, Check Every Shift that you are AVAILABLE to Work (Check all that apply):
SUNDAY AVAILABILITY:
*For the Shifts that you are NOT AVAILABLE: LEAVE BLANK
Early Mornings (7:00 AM- 3:00 PM)
Evenings (3:00 PM- 11:00 PM)
Mid/Overnights (11:00 PM- 7:00 AM)
THURSDAY AVAILABILITY:
*For the Shifts that you are NOT AVAILABLE: LEAVE BLANK
Early Mornings (7:00 AM- 3:00 PM)
Evenings (3:00 PM- 11:00 PM)
Mid/Overnights (11:00 PM- 7:00 AM)
MONDAY AVAILABILITY:
*For the Shifts that you are NOT AVAILABLE: LEAVE BLANK
Early Mornings (7:00 AM- 3:00 PM)
Evenings (3:00 PM- 11:00 PM)
Mid/Overnights (11:00 PM- 7:00 AM)
FRIDAY AVAILABILITY:
*For the Shifts that you are NOT AVAILABLE: LEAVE BLANK
Early Mornings (7:00 AM- 3:00 PM)
Evenings (3:00 PM- 11:00 PM)
Mid/Overnights (11:00 PM- 7:00 AM)
TUESDAY AVAILABILITY:
*For the Shifts that you are NOT AVAILABLE: LEAVE BLANK
Early Mornings (7:00 AM- 3:00 PM)
Evenings (3:00 PM- 11:00 PM)
Mid/Overnights (11:00 PM- 7:00 AM)
SATURDAY AVAILABILITY:
*For the Shifts that you are NOT AVAILABLE: LEAVE BLANK
Early Mornings (7:00 AM- 3:00 PM)
Evenings (3:00 PM- 11:00 PM)
Mid/Overnights (11:00 PM- 7:00 AM)
WEDNESDAY AVAILABILITY:
*For the Shifts that you are NOT AVAILABLE: LEAVE BLANK
Early Mornings (7:00 AM- 3:00 PM)
Evenings (3:00 PM- 11:00 PM)
Mid/Overnights (11:00 PM- 7:00 AM)
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VII. SIGNATURE, ACKNOWLEDGEMENTS, and ATTACHMENTS
Copy of Attach Copy of Your Resume
*If you have an electronic file of your Resume, letter of recommendation, etc... that you wish to submit with your Employment Application, you may attach them by uploading them Here (.pdf, .doc, or .docx formats only):
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Employment Instruction and Requirements Acknowledgement
*By checking this box, I certify that I have read, understand, and agree with the
Employment Introduction and Requirements
Applicant's Statement Acknowledgement
*By checking this box, I certify that I have read, understand, and agree with the
Applicant's Statement
*Applicant's Electronic Signature
*By signing, you agree that you have read, understand, and agree with the "Applicant's Statement" and "Employment Instruction & Requirements" above.
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