Independence 4 Seniors

Last Name*:

Address*:

Zip Code*:

First Name*:

City*:

Phone*:

Middle Initial:

State*:

Email Address*:

Have you ever been convicted, pled no contest, or received deferred adjudication for a criminal offense including traffic violations?

Yes No

Are there criminal charges currently pending against you for any offense including traffic violations?

Yes No

If yes, please provide date of offense, city/county/state, nature of offense and current disposition.

Year:

Year:

Year:

Offense:

Offense:

Offense:

City/State:

City/State:

City/State:

Note: Answering "yes" will not automatically result in the applicant being disqualified from employment and that qualification for employment will depend upon the nature of the charges and other information, such as the status of the proceeding and the underlying facts.

Are you authorized to legally work in the United States?*
Yes No

If you answered YES to the above question, which of the following applies to you:

  Citizen of the United States

  Lawful Permanent Resident (Green Card)

  Authorization to Work (Work Permit)

(NOTE: Proof of citizenship or immigration status will be required upon employment)

#1) Current Employer:

Position Held:

Supervisor:

Phone Number:

From:

Reason for Leaving:

City/State:

To:

May We Contact Them?
Yes No

#2) Past Employer:

Position Held:

Supervisor:

Phone Number:

From:

Reason for Leaving:

City/State:

To:

May We Contact Them?
Yes No

#3) Past Employer:

Position Held:

Supervisor:

Phone Number:

From:

Reason for Leaving:

City/State:

To:

May We Contact Them?
Yes No

High School:

City/State:

Did You Graduate?
Yes No

College:

City/State:

From:

To:

Degree(s):

CNA Program:

City/State:

From:

To:

Degree(s):

City of Chicago

Western Cook County (LaGrange, Brookfield, LaGrange Park, Western Springs, Westchester, etc.)

East DuPage County (Hinsdale, Oak Brook, Willowbrook, Elmhurst, Westmont, Clarendon Hills, etc.)

West DuPage County (Lisle, Naperville, Wheaton, etc.)

When providing transportation to a client, are you comfortable driving your car?

Or driving your client's car?

Yes No

Yes No

Morning

Evening

Overnight

How many hours per week are you able to work?

Are you available to work every other weekend?

Yes No

Desired Salary Range?

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Employee:

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Employment Eligibility: Immigration Act
I understand that, if hired, I will be required to present documentary evidence proving that I am currently authorized to work in the United States either by proof of US citizenship, Permanent Resident Card (Green Card) or Employment Authorization Card. I also understand that my continued employment is contingent upon my providing the necessary documentation within the prescribed timeframes.

Authorization and Understanding
I certify that the information given herein is true and complete without qualification. I understand that Independence-4-Seniors will review the information given on this application and, if initial criteria are satisfied, will call me to schedule an in-person interview at the agency office. I understand and acknowledge that, if hired, Independence-4-Seniors can terminate my employment if I have provided incomplete, inaccurate, untrue or misleading information on this application or on any other document or form at any time during my employment. I agree to conform to the rules and regulations of Independence-4-Seniors and, if employed, I understand and agree that my employment is at-will and that no employment contract rights have been created. I also understand and agree that my employment may be terminated at any time with or without cause, and with or without advance notice at the option of either Independence-4-Seniors or myself.

Full Name*:

Date*: (MM/DD/YYYY)

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