Employment Application Step 1 of 5 20% Applicant InformationName First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneCell PhoneEmail 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 ExperienceHigh SchoolWhat 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 CollegeWhat college did you attend? Date Attended MM slash DD slash YYYY To MM slash DD slash YYYY College Address Degree Received Degree Received OtherOther (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: Employment History Please begin with present or most recent employment.Current or Most Recent EmploymentEmployer Name Date Employed MM slash DD slash YYYY To MM slash DD slash YYYY Employer Address Employer PhoneJob Title & ResponsibilitiesPrevious EmploymentEmployer Name Date Employed MM slash DD slash YYYY To MM slash DD slash YYYY Employer Address Employer PhoneJob Title & ResponsibilitiesPrevious EmploymentEmployer Name Date Employed MM slash DD slash YYYY To MM slash DD slash YYYY Employer Address Employer PhoneJob Title & ResponsibilitiesAre you currently employed? Yes No May we contact your current employer? Yes No 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 Name Relation Email PhoneRefererence #2Reference Name Relation Email PhoneRefererence #3Reference Name Relation Email Phone Emergency ContactEmergency Contact Name PhoneUpload your resumeAccepted file types: pdf, Max. file size: 256 MB.Please upload a .pdf of your resume to be considered for employment.* 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 Δ