TAILORED SUPPORT SERVICES
APPLICANT INFORMATION & POSITION REQUESTED
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
Please complete all applicable fields. An incomplete application may delay consideration.
1. APPLICANT INFORMATION
Full Legal Name
First Name
Last Name
Preferred Name
First Name
Last Name
Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Are you at least 18 years of age?
Yes
No
Are you legally authorized to work in the United States?
Yes
No
2. POSITION REQUESTED
Position(s) applying for:
Homemaker
Companion
Homemaker & Companion
PRN / On-Call Support Staff
Supported Living Coach
Supported Employment Coach
Other
Employment desired:
Full-Time
Part-Time
PRN / On-Call
Temporary
Date available to begin
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Desired hours per week
Desired pay
3. GENERAL AVAILABILITY
Check all that generally apply:
Day Shift
Evening Shift
Overnight
Weekends
Holidays
Short Notice / Call-In
Varied Client Schedules
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TAILORED SUPPORT SERVICES
QUALIFICATIONS, CERTIFICATIONS & AVAILABILITY
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
4. TRAINING & CERTIFICATIONS
Check all current certifications/training:
CPR
First Aid
AED
BLS
Medication Assistance Training
HIV/AIDS Training
Infection Control
Behavior Support
Client Rights
Abuse / Neglect Reporting
Food Safety
Other
Other certification/training
Expiration date(s), if applicable
5. SUPPORT SERVICES EXPERIENCE
Check all areas in which you have prior experience:
Older Adults / Seniors
Developmental Disabilities
Adults with Disabilities
Companion Services
Light Housekeeping
Meal Preparation
Errands / Shopping
Community Outings
Service Documentation
Safety Monitoring
Behavior Support
Families / Caregivers
Total years of relevant experience
Most recent client population served
6. WEEKLY AVAILABILITY
6. WEEKLY AVAILABILITY
Rows
Day
Evening
Overnight
Not Available / Notes
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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TAILORED SUPPORT SERVICES
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
EMPLOYMENT HISTORY - PART 1
7. EMPLOYMENT HISTORY
List your most recent employer first. Include relevant caregiving, homemaker, companion, healthcare, or service experience.
EMPLOYER 1
Employer / Organization
Position
Supervisor
Phone
Format: (000) 000-0000.
Dates Employed
Reason for leaving
Primary duties
May we contact this employer?
Yes
No
EMPLOYER 2
Position
Employer / Organization
Supervisor
Phone
Format: (000) 000-0000.
Dates Employed
Reason for leaving
Primary duties
May we contact this employer?
Yes
No
Tailored Support Services - Employment Application
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TAILORED SUPPORT SERVICES
EMPLOYMENT HISTORY & PROFESSIONAL REFERENCES
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
7. EMPLOYMENT HISTORY - CONTINUEDEMPLOYER 3
Employer / Organization
Position
Supervisor
Phone
Format: (000) 000-0000.
Dates Employed
Reason for leaving
Primary duties
May we contact this employer?
Yes
No
8. PROFESSIONAL REFERENCES
Please provide three professional references who are not relatives.
Reference 1 - Name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
Years Known
Reference 2 - Name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
Years Known
Reference 3 - Name
Relationship
Phone
Format: (000) 000-0000.
Email
example@example.com
Years Known
Tailored Support Services - Employment Application
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TAILORED SUPPORT SERVICES
CLIENT SUPPORT SKILLS & PROFESSIONALISM
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
9. CLIENT SUPPORT SKILLS
Can you reliably report to assigned client visits on time and remain for the full scheduled service period?
Yes
No
Are you comfortable completing accurate service notes, timesheets, and required documentation?
Yes
No
Can you maintain client confidentiality and professional boundaries?
Yes
No
Are you willing to follow service instructions, agency policies, and supervisor direction?
Yes
No
Can you perform the essential functions of the position, with or without reasonable accommodation?
Yes
No
Briefly describe any experience you have supporting client independence and choice:
Describe your approach to professional boundaries when working in a client's home:
10. SAFETY & PROFESSIONAL CONDUCT
Are you willing to follow emergency procedures and promptly report safety concerns?
Yes
No
Do you understand your obligation to promptly report suspected abuse, neglect, or exploitation?
Yes
No
Can you report to work free from impairment and remain alert throughout your assigned service period?
Yes
No
Can you meet agency appearance, identification, and professionalism standards?
Yes
No
Can you limit personal phone use while providing client services except for work or emergencies?
Yes
No
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TAILORED SUPPORT SERVICES
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
SCENARIO QUESTIONS
11. SCENARIO QUESTIONS
Please answer each scenario based on how you would respond in a professional client-support setting.
A client refuses a scheduled task or activity. How would you respond while respecting the client's rights and documenting the situation?
You notice a meaningful change in a client's condition, behavior, or home environment. What would you do?
A family member asks you to perform a task that is outside the approved service plan or agency policy. How would you respond?
A client becomes upset or verbally frustrated. How would you de-escalate the situation while maintaining professionalism?
Tailored Support Services - Employment Application
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TAILORED SUPPORT SERVICES
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
TRANSPORTATION & ADDITIONAL QUALIFICATIONS
12. DRIVING ELIGIBILITY - COMPLETE IF APPLICABLE TO THE POSITION
Some assignments may involve errands, community outings, or client transportation when authorized.
Do you possess a valid driver license?
Yes
No
Driver License State
License Number
Do you have reliable transportation to and from client assignments?
Yes
No
If required, are you willing to provide authorized client transportation in an approved vehicle?
Yes
No
If using a personal vehicle for authorized work, do you maintain current automobile insurance?
Yes
No
Insurance Company
Policy Expiration
List any driving restrictions relevant to job duties:
13. ADDITIONAL QUALIFICATIONS
Languages spoken other than English:
Technology you are comfortable using (smartphone apps, electronic visit verification, email, etc.):
Additional skills, training, or experience you would like us to consider:
Tailored Support Services - Employment Application
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Expiration Date
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TAILORED SUPPORT SERVICES
DOCUMENTS, AUTHORIZATION & APPLICANT CERTIFICATION
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
14. APPLICATION DOCUMENT CHECKLIST
If requested during the hiring process, be prepared to provide applicable documentation:
Government-issued photo identification
Driver license, if driving is part of the position
Proof of automobile insurance, if applicable
CPR / First Aid certification, if applicable
Relevant training certificates
Resume or employment history
Other requested onboarding documents
15. VERIFICATION & BACKGROUND SCREENING NOTICE
Tailored Support Services may verify job-related information provided in this application, including employment history, professional references, credentials, training, driving eligibility when relevant, and other qualifications permitted by law. Any background investigation or consumer report requiring a separate disclosure or authorization will be handled through the appropriate process. Submission of this application does not guarantee employment.
Applicant Initials
16. APPLICANT CERTIFICATION
I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that materially false or misleading information may disqualify me from consideration or may result in disciplinary action if discovered after employment, subject to applicable law. I understand that employment, if offered, is subject to applicable agency requirements, policies, verification, and onboarding procedures.
Applicant Printed Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Applicant Signature
Optional comments or information you would like the hiring team to know:
Tailored Support Services - Employment Application
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TAILORED SUPPORT SERVICES
FOR COMPANY USE ONLY
Employment Application
1211 W. Tharpe Street | Tallahassee, FL 32303
Office 833-659-6989 | www.tailoredsvcs.com
APPLICATION REVIEW
Application Received
Interview Date
Interviewer
ID Verified
References Checked
Background Process Initiated
Driver License Verified, if applicable
Auto Insurance Verified, if applicable
Certifications Verified:
CPR
First Aid
BLS
Other
Other
INTERVIEW RECOMMENDATION
Highly Recommended
Recommended
Consider for PRN / On-Call
Hold
Not Recommended
Position Offered
Starting Rate
Proposed Start Date
Hiring / Interview Notes
ONBOARDING STATUS
Offer / Conditional Offer Completed
Orientation Scheduled / Completed
Policies / Handbook Acknowledged
Required Training Completed
Hiring Manager / Authorized Reviewer
Date
Tailored Support Services - Employment Application
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