ILS Employment Application Form

Employment Application

Prospective employees must provide additional out of state address(es) if they have resided in CT for less than 3 years.
Personal Information
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you lived outside of CT within the past 3 years, please list prior addresses with years and months lived at each address
Employment History and Work References
Please Explain Any Gaps of Employment Over 6 Months*
Resume and Files

Cancelof
Other References or Employment (Please Do Not List Relatives or Friends)
Please list two (2) references that are familiar with your work life.*
Applying for Position *
Release of Information Authorization - I do hereby give permission for the release of any and all information from employment, education, and personal references to Independent Living Solutions for the sole purpose of conducting and employment check for the position selected.
Availability
Are you less than 18 years of age?*

YesNo
Are you eligible to work in the US?*

YesNo
Car Available*

YesNo
Willing to Accept Last Minute Assignments?*

YesNo
What days are you available to work? (Check all that apply)

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Date Available for Work

MonthDayYear
Date
Available to Work Holidays?*

YesNo
When are you available to work? (Check all that apply)

MorningsAfternoonsEveningsOvernights
Education
High School / Tech School

School NameSchool Location
College / University

School NameSchool Location
Other Training / Education

School NameSchool Location
Emergency Contact

Emergency Contact NameEmergency Contact Phone
Background and Certification
Have you ever worked for Independent Living Solutions before?*

YesNo
How did you hear about us?*

AdvertismentJob FairFamily/FriendSearch EngineOther (please specify)
Have you ever cared for an elderly/disabled person? Please explain. Care Explanation
Have you ever been convicted if a crime in any state?*

YesNo
If Yes, please provide additional information. Conviction Info
Have you ever been discharged by a prior employer?*

YesNo
If Yes, please provide additional information. Discharge Info
Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or foreign jurisdiction?*

YesNo
Have you been convicted of a crime involving violence or dishonesty in a state court or federal court of law in any state, or been subject to any decision imposing disciplinary action by a licensing jurisdiction?*

YesNo
I CERTIFY THAT THE STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ARE MADE IN GOOD FAITH. I UNDERSTAND THAT IF I KNOWINGLY MAKE ANY MISSTATEMENTS OF FACT, I AM SUBJECT TO DISQUALIFICATION, DISMISSAL, OR OTHER ACTION PURSUANT TO EMPLOYMENT AGENCY POLICY AND PROCEDURE, AND SUBJECT TO CRIMINAL PENALTIES AS PRESCRIBED BY THE LAW.

Powered by Jotform SignClear
Under Connecticut law (1) You need not disclose the existence of any arrest, criminal charge or conviction that has been erased; (2) records subject to erasure for these purposes are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty, and a conviction for which a person received an absolute pardon; and (3) any person whose criminal records have been so erased shall be deemed never to have been arrested with respect to the erased records and may so swear under oath. Independent Living Solutions is an equal opportunity employer committed to hiring a diverse workforce.
Submit Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Employment Application

Personal Information

Employment History and Work References

Availability

Education

Background and Certification