[Tuesday: Wednesday: Thursday: Friday: [Saturday: What is the minimum number of hours you will work in one day? What is the maximum number of hours you will work in one day? When can you start working?
Yes or No (circle) List any work limitations that you may have and briefly describe:
**Attach resume** *Attach Certificate** *attach Recommendation Letter**
What locations are you willing/able to work? select all that apply) Virginia BeachChesapeake Newport NewsWilliamsburg
Eastern Shore (Northampton Co)
Transportation Transportation Walver form)
Do you have reliable transportation? Do you have adequate vehicle insurance? Are you willing to drive a client's vehicle?
Do you have a valid Driver's License or Identification Card?
Have you ever been investigated for abuse, neglect or domestic violence? YesNo
Do you have a criminal background? Do you have any upcoming criminal cases pending? If yes, explain: