Job Application – Lending Hands 4 U

Name *

First

Middle

Last

Date Of Birth *

Present Address *

Address Line 1

City

State

Zip Code

Home Phone *

Cell *

Email *

Date available for work:

Rate of pay expected:

Are you 21 years of age: *

Valid Driver’s License: *

Are you legally authorized to work in the United States and have documentation verifying that authority? *

Applying Position:

Referral Source:

Seeking Full-Time, 40HRS per week and Open to All Shifts:

Seeking Part- Time less than 30 HRS per week, Specific Days and Hours:

Have you ever worked for or with someone who is disabled: *

Circle which term you like best:

IF you saw someone in a wheelchair and they dropped something on the ground, would you:

Have you ever been sanctioned by the Department of Health and Human Services with regard to the Medicare/Medicaid program, Central background check, or any other federal program?

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