APPLICATION FOR PERSONAL ASSISTANT

 Note :   You are applying for a personal assistant position.  Mike will receive your application as soon as you click the 'submit application below.  He will contact you directly if he determines that you qualify for an interview.  Before filling out this application, please review the job description here.  If you have any questions for Mike, please e-mail him at mmatz1@newhaven.edu.

 

  ENTER TODAY'S DATE: 

Please provide the following contact information:

First Name
Middle Initial
Last Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Home Phone
School Phone
Cell Phone
E-mail

 

EDUCATIONAL BACKGROUND:

High School  College      Other
 other, please explain:
COLLEGE ATTENDED/ATTENDING:
TOTAL COLLEGE CREDITS EARNED:
(EXPECTED) GRADUATION DATE:
MAJOR:
GPA:
   

 GENERAL BACKGROUND

WHAT INTERESTS YOU ABOUT THIS POSITION?
DO YOU HAVE ANY RELATED WORK EXPERIENCE? Yes  No
If Yes, please explain
HAVE YOU EVER BEEN ARRESTED? Yes No
If yes, please explain:
HAVE YOU EVER BEEN CONVICTED OF A FELONY? Yes No
If yes, please explain:
DO YOU HAVE A VALID DRIVER'S LICENSE? Yes No

 

TASKS

The list below contains many tasks necessary to daily living. For each task, please indicate your level of comfort with performing that task properly in an efficient and responsible manner.  Then provide as many as you can about any experience with performing the task in the space on the right.  If you don't have any experience the a specified task, please provide any questions, thoughts or concerns that you may have about the task.
Assisting with: Comfort level: Details:
Dressing/Undressing
Eating/Drinking
Bathing/Brushing teeth
Toileting functions
Getting in and out of bed
Driving a conversion van
General household chores
Getting in/out of pool
 

Listed below is an optional section containing some skills/statements that may or may not be useful in considering you for a specific position.  Please give an honest assessment of yourself by selecting the most accurate rating for the items below.  You may elaborate if you wish in the space provided on the right.
:    
My ability to pay close attention to details when following written/oral instructions is
My ability to remain calm in unexpected situations is
My physical strength/ability to lift is
My tolerance level of basic bodily functions are
My telephone/phone presence skills are
My small talk/conversation skills are
My computer skills are
Self-Presentation/Body Language skills
My networking skills are
 

 

 

 



 

 

 

 

 

 

 

 

AVAILABILITY

Please provide an overall sense of your general availability for the next few months.

 
What is the maximum number of hours that you would be available to work per week?
Please state the days and times that you are available during the week/weekends.

Would you be available for a roommate shift?    (more information) Yes No Not Sure
If yes, what would be the maximum number of days per week that you are available for the roommate shift? 1  23 Not Sure
In an emergency, would you be willing to fill in during someone else's shift? Yes No
Please list the times in which you are absolutely unavailable to work or fill in for other shifts.

 
PLEASE STATE ANY OTHER INFORMATION THAT YOU WOULD LIKE TO BE CONSIDERED IN YOUR APPLICATION FOR THIS POSITION.

REFERENCES: List names, phone numbers, and e-mail addresses three prior employers.
  NAME PHONE E-MAIL COMPANY
Reference # 1
Reference # 2
Reference # 3
 

I certify that all answers given here are true and complete to the best of my knowledge. 

Yes  No

(only click ONCE)(clears the application)

 
                            


                                                
 
                                                
 Created by Mike 

Copyright © 2007 [M.M.]. All rights reserved. 

 Revised: 08/27/11