Employment Application

Applicant Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Cell Phone
Email
Date of Birth
MM slash DD slash YYYY
What services are you interested in providing?
- Attendant Care
- Respite
- Habilitation
Do you have OR can you obtain a First Class Fingerprint Clearance Card?
This means you are at least 18 years of age, with no arrests, no convictions and are not currently awaiting trial.
- Yes
- No
If YES, Fingerprint Clearance Card Number
Expiration Date
MM slash DD slash YYYY
Can you provide proof of eligibility to work in the US?
(Social Security Card, AZ Driver's License, State issued ID Card OR Passport)
- Yes
- No

Education and Experience
High School
What high school (GED) did you attend?
Date Attended
MM slash DD slash YYYY
To
MM slash DD slash YYYY
High School Address
Degree Received
Area of Study
College
What college did you attend?
Date Attended
MM slash DD slash YYYY
To
MM slash DD slash YYYY
College Address
Degree Received
Degree Received
Other
Other (please specify)
Date Attended
MM slash DD slash YYYY
To
MM slash DD slash YYYY
School Address
Degree Received
Please indicate your experience implementing and documenting performance in individual programs OR any habilitation training you may have received.
Please indicate your experience providing assistance to meet an individuals’ personal, physical and emotional needs:

References

Please provide three (3) non-family references who have personal knowledge about your employment history, education or character. Please have your references complete the reference request forms.
Refererence #1
Reference Name
Relation
Email
Phone
Refererence #2
Reference Name
Relation
Email
Phone
Refererence #3
Reference Name
Relation
Email
Phone

Emergency Contact
Emergency Contact Name
Phone
*
- I certify that the information contained in this application is correct to the best of my knowledge, and I understand that any false statements or misrepresentation is sufficient grounds for ending the hiring process or dismissal. In consideration of my employment, I agree to conform to the rules and regulations of TLC Services, LLC and the State of Arizona Division of Developmental Disabilities. I authorize investigation of all statements contained herein. I understand that no representative of TLC Services other than the hiring manager has the authority to enter into any agreement for employment.
Applicant Signature

Applicant Information