Apply Now Apply Now Please enable JavaScript in your browser to complete this form.Personal Information *FirstLastProspective employees must provide additional out of state address(es) if they have resided in CT for less than 3 years Email *EmailConfirm EmailPhoneAddress *Address Line 1Address Line 2CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf 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 *LayoutDate / Time *Date / Time (copy) *Phone *Address *Address Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob Title *Supervisor *Describe Your Duties *Reason You Left *Employer 2 *LayoutDate / Time *Date / Time *Phone *Address *Address Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob Title 2 *Supervisor 2 *Duties 2 *Reason You Left 2 *Please Explain Any Gaps of Employment Over 6 MonthsOther References or Employment (Please Do Not List Relatives or Friends) *Years Known *Phone *Address *Address Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRelationship to Applicant *Other References or Employment 2 *Years Known 2 *Phone 2 *Address 2 *Address Line 1CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRelease of Information Authorization* Clear Signature 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 of: DROP DOWN OF POSITIONS? Companion, Independent Living Skills Trainer (ILST), Recovery Assistance, Job Coach, Volunteer, Other. Relationship to Applicant 2 * Availability Are you less than 18 years of age? *YesNoAre you eligible to work in the US? *YesNoCar Available *YesNoWilling to Accept Last Minute Assignments? *YesNoWhat days are you available to work? (Check all that apply)SundayMondayTuesdayWednesdayThursdayFridaySaturdayDate Avalible for work *Desired Number of Hours Per Week *Available to Work Holidays? *YesNoWhen are you available to work? (Check all that apply)MorningsAfternoonsEveningsOvernights Education High School / Tech School *High School / Tech School Location *College / University *College/University Location *Other Training / EducationHigh School / Tech School (copy)Emergency Contact Name *Phone * Background and Certification Have you ever worked for Independent Living Solutions before? *YesNoHow did you hear about us *AdvertisementJob FairFamily/FriendSearch EngineOtherPlease explain. *Have you ever been convicted if a crime in any state? *YesNoHave you ever been convicted if a crime in any state? *Have you ever been discharged by a prior employer? *YesNoHave you ever been discharged by a prior employer? *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? *YesNoHave 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? *YesNoHave 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? *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. Electronic Signature * Clear Signature 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. Signature Date *Submit
