Family Works Employment Application

Applicant Information

	Last Name*	First Name*	DOB*

	Address*	Apartment/Unit #

City*

State/Region*

Zip Code*

Enter Region

Phone*

E-mail Address

Would you like to receive quarterly emails from Family Works?

()-ext

Enter Int'l Number

YesNo

	Social Security Number*
	- -

	Are you a citizen of the United States?*	If no, are you authorized to work in the U.S.?
	YesNo	YesNo

	Have you lived outside of Wisconsin in the last five years?*	If yes, please list states and dates lived there.
	YesNo

	Please list and explain any legal history (including dates).*

	Do you have a valid drivers license?*	Issued in which state?	Please enter your drivers license number.
	YesNo

	Please list all driving citations and moving violations (including dates) within the last five years.*	Do you have access to a safe, reliable vehicle that could be used to transport clients (mileage reimbursed)?
		YesNo

	Position Applied For:*

	How did you hear about us?

Education
Please enter information for the highest level of education completed or enrolled in.

References

Please provide contact information for at least 4 references.

Please enter the number of references.

Employment History

Please provide contact information for all employers for the past 5 years.

Please enter the number of jobs.

Additional Certifications
Do you have any other skills, qualifications, training or experience which you feel would qualify you for this position?

Special Interests/Hobbies
When you have a day off how do you enjoy spending it?

Please use the section below to upload your resume or other pertinent documents.

Resume & Other Documents
Upload Documents*	Document Uploaded Upload New/Replace Existing

Please select all hours/shifts you are available to work.

Availability Grid
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday * note: every other weekend required
Sunday * note: every other weekend required.
Minimum number of hours per week.
Maximum number of hours per week.
Additional comments regarding availability.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I hereby authorize Family Works, Inc. to obtain the information necessary for employment verification. Additionally, I release the above stated employers from all liability whatsoever for issuing the requested information.

Signature and Date

	Signature:*	Date*

	Name*	Relationship*

	Email*

	Name*	Relationship*

	Email*