Full Legal Name *

Preferred Name

Date of birth *

Social Security Number *

Phone *

Email *

Are you legally authorized to work in the U.S.? *

Can you provide valid I-9 documents? *

Position Applying For *

Valid Driver's License Number, State and Expiration Date *

Do you have reliable transportation? *

Do you have current auto insurance? *

Auto Insurance Company Name: *

Auto Insurance Policy Number *

Auto Insurance Expiration Date *

Year, Make & Model of Vehicle *

How did you hear about Anchored PAS, LLC?

Please indicate the types of services which you are willing to provide: **To provide transportation or run errands, you’ll need a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted, and proof of insurance will also be required.

Are you willing to provide service to client to a client that smokes? *

Are you willing to provide service to client with a pet? *

If yes, which one do you prefer: *

Have you ever served in the military?

Service Branch:

Please select the highest level of education you have completed: *

High School Name

City and State

Major/ Subject

Numbers of Years Attended

Graduate?

Vocational/ Technical School Name

City and State

Major/ Subject

Number of Years Attended

Graduate?

College/ University Name

City and State

Major/Subject

Number of Years Attended

Graduate?

Are you currently working for this employer? *

If yes, may we contact them? *

Most Recent Employer *

Company Name

City and State *

Phone Number *

Dates Employed: *

MM/YYYY TO MM/YYYY

Job Title *

Supervisor's Name *

Duties

Please fill out this section by indicating your desired pay rate: $_____per _______(Hour,Week, or Month)

Reason for Leaving

SECOND MOST RECENT EMPLOYER

Company Name

City and State

Phone Number

Dates Employed:

MM/YYYY TO MM/YYYY

Job Title

Supervisor's Name

Duties

Please fill out this section by indicating your desired pay rate: $____per______ (Hour, Week or Month)

Reason for Leaving

THIRD MOST RECENT EMPLOYER

Company Name

City and State

Phone Number

Dates Employed:

MM/YYYY TO MM/YYYY

Job Title

Supervisor's Name

Duties

Please fill out this section by indicating your desired pay rate: $______ per ________ (hour, week, or month) *

Reason for Leaving

Are you a citizen of United States or do you have the legal right to be employed in the United States?

As a condition of employment all employees must be " Bondable" & "Insurable". Are you at least 19 years of age?

Have you had any moving traffic violations? *

If yes, please describe:

Anchored Personal Assistance Services, LLC

Employment Application