Employment Application Step 1 of 5 20% Applicant InformationName First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneCell PhoneEmail Date of Birth Date Format: 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.YesNoIf YES, Fingerprint Clearance Card NumberExpiration Date Date Format: 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)YesNo Education and ExperienceHigh SchoolWhat high school (GED) did you attend?Date Attended Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY High School AddressDegree ReceivedArea of StudyCollegeWhat college did you attend?Date Attended Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY College AddressDegree ReceivedDegree ReceivedOtherOther (please specify)Date Attended Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY School AddressDegree ReceivedPlease 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: Employment History Please begin with present or most recent employment.Current or Most Recent EmploymentEmployer NameDate Employed Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Employer AddressEmployer PhoneJob Title & ResponsibilitiesPrevious EmploymentEmployer NameDate Employed Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Employer AddressEmployer PhoneJob Title & ResponsibilitiesPrevious EmploymentEmployer NameDate Employed Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Employer AddressEmployer PhoneJob Title & ResponsibilitiesAre you currently employed?YesNoMay we contact your current employer?YesNo 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 #1Reference NameRelationEmail PhoneRefererence #2Reference NameRelationEmail PhoneRefererence #3Reference NameRelationEmail Phone Emergency ContactEmergency Contact NamePhone* 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