Applicant Name
*
First Name
Last Name
Email
*
Date of Birth
*
Street Address
*
Phone
(###)
###
####
Have you ever been / are you currently employed as a Vocational Rehabilitation Intern / Counselor in WA state?
If yes, most recent:
Have you ever filed for a workers' compensation claim with the Department of Labor & Industries?
Have you ever applied for employment at Vocational Vistas, Inc.?
Do you own or have unliomited access to a reliable vehicle for work-related purposes?
Do you have auto insurance?
*If hired, you will be asked to provide a photocopy of your driver's license and proof of insurance.
Are you able to present evidence of your US citizenship or proof of your legal right to work in the United States?
*If hired, you will be asked to complete an I-9 Form (Employment Eligibility Verification).
If hired, are you willing to submit to a controlled substance test?
Position Applying For:
High School Name:
Did you graduate?
Year Degree / Diploma earned:
College / University Name:
Number of years completed:
Did you graduate?
Degree (s) / Certificate (s) Earned:
Year Degree / Certificate (s) earned:
Vocational School Name:
Did you graduate?
Degree (s) / Certificate (s) Earned:
Years Degree (s) / Certificate (s) Earned:
Military Branch:
Rank in Military:
Total Years of Service:
Skills / Duties:
Related Details
Skills and Qualifications:
Licenses, Skills, Training, Awards:
Do you speak, write or understand any foreign languages?
If yes, list which languages and how fluent you consider yourself to be:
Are you currently employed?
May we contact your previous employer(s)?
Employer Name:
Name of Supervisor
Phone
(###)
###
####
Business Type:
Address / Location:
Length of Employment (Include Dates):
Salary / Hourly Rate of Pay:
Position & Duties:
Reason for Leaving:
Employer Name:
Name of Supervisor:
Phone
(###)
###
####
Business Type:
Address / Location:
Length of Employment (Include Dates):
Salary / Hourly Rate of Pay:
Position & Duties:
Reason for Leaving:
Employer Name:
Name of Supervisor:
Phone
(###)
###
####
Business Type:
Address / Location:
Length of Employment (Include Dates):
Salary / Hourly Rate of Pay:
Position & Duties:
Reason for Leaving:
May we contact your professional references?
Name
First Name
Last Name
Phone
(###)
###
####
Email
Address | City, State, Zip:
Occupation:
Number of Years Acquainted:
Name
First Name
Last Name
Phone
(###)
###
####
Email
Address | City, State, Zip:
Occupation:
Number of Years Acquainted:
Name
First Name
Last Name
Phone
(###)
###
####
Email
Address | City, State, Zip:
Occupation:
Number of Years Acquainted:
Certification
*
I certify that the information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment if I am hired. I authorize the verification of any and all information listed above.
