1055 Wilshire Blvd., Suite 850, Los Angeles, CA 90016 Tel. (213) 204-1000 Fax (213) 221-4016 www.giantsteps.net EMPLOYMENT APPLICATION

Revised: 08/03/15

GENERAL INFORMATION FIRST NAME MIDDLE INITIAL LAST NAME HOW DID YOU HEAR ABOUT US?

STREET ADDRESS CITY STATE ZIP CODE

HOME PHONE NUMBER CELLULAR PHONE NUMBER E-MAIL ADDRESS ARE YOU LEGALLY ALLOWED TO WORK IN THE U.S.? YES o NO o

HAVE YOU EVER APPLIED FOR GIANT STEPS BEFORE? YES o NO o If yes, when?

DO YOU HAVE ANY FRIENDS OR RELATIVES WORKING FOR GIANT STEPS? YES o NO o If yes, who? Relationship:

EMPLOYMENT DESIRED POSITION APPLYING FOR DATE YOU CAN START SALARY DESIRED CHECK ALL THAT APPLY:

FULL TIME o PART TIME o TEMPORARY WORK o

ANY DAY o ANYTIME o

If you are unavailable any day or anytime, indicate the hours of availability for each day of the week. MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

IF YOU ARE APPLYING FOR A DRIVER POSITION, INDICATE YOUR CLASS OF LICENSE A o B o Passenger Endorsement o C o

DO YOU HAVE A CURRENT DMV MEDICAL CERTIFICATE? YES o NO o

DO YOU HAVE A CURRENT DRIVER’S LICENSE? YES o NO o

EDUCATION NAME OF HIGH SCHOOL DATES ATTENDED DID YOU GRADUATE?

YES o NO o GPA

NAME OF COLLEGE OR UNIVERSITY DATES ATTENDED DEGREE (IF ANY) MAJOR GPA

NAME OF OTHER TRADE OR TRAINING SCHOOLS DATES ATTENDED CERTIFICATIONS/DEGREES SUBJECTS STUDIED

WORK EXPERIENCE

Are you currently employed? YES o NO o If yes, may we contact your current employer? YES o NO o COMPANY NAME CITY, STATE PHONE NUMBER SUPERVISOR

JOB TITLE DUTIES

START DATE END DATE STARTING SALARY ENDING SALARY REASON FOR LEAVING

COMPANY NAME CITY, STATE PHONE NUMBER SUPERVISOR

JOB TITLE DUTIES

START DATE END DATE STARTING SALARY ENDING SALARY REASON FOR LEAVING

COMPANY NAME CITY, STATE PHONE NUMBER SUPERVISOR

JOB TITLE DUTIES

START DATE END DATE STARTING SALARY ENDING SALARY REASON FOR LEAVING

You may also submit this application by emailing it to apply@giantsteps.net or by faxing it to (213) 221-4016.

SKILLS INFORMATION RATE YOURSELF ON THE EXPERIENCE WITH THE FOLLOWING SKILLS (CHECK BOXES ON RIGHT)

NO EXPERIENCE FAIR GOOD EXCELLENT COMMENTS

Using Public Transportation

General Home Care (Cooking, Cleaning, Laundry)

Familiarity With Public Assistance Programs

Familiarity With Los Angeles Area

Transferring Persons In/Out of Wheelchairs

Writing Progress Reports

Computer/Internet Knowledge

Clothing/Retail

Driving

Other:

LICENSES AND CERTIFICATES NAME OF LICENSE OR CERTIFICATE ISSUING AGENCY ISSUING STATE LICENSE OR CERTIFICATE NUMBER EXPIRATION DATE

NAME OF LICENSE OR CERTIFICATE ISSUING AGENCY ISSUING STATE LICENSE OR CERTIFICATE NUMBER EXPIRATION DATE

REFERENCES List below three persons not related to you who have knowledge of your work performance within the last three years. NAME RELATIONSHIP PHONE NUMBER OCCUPATION YEARS ACQUAINTED

NAME RELATIONSHIP PHONE NUMBER OCCUPATION YEARS ACQUAINTED

NAME RELATIONSHIP PHONE NUMBER OCCUPATION YEARS ACQUAINTED

Have you ever been convicted for any violation(s) of the law? YES o NO o If yes, please describe offense:

Please why you would be a good candidate for the position you are applying for:

Please state why you chose GIANT STEPS:

I hereby certify that all entries on this application are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment at GIANT STEPS TRAINING PROGRAMS, INC. I understand that all information on this application is subject to verification and I consent to criminal history and DMV background checks. I also consent to references and former employers and educational institutions listed being contacted regarding this application. I further understand that if hired, my employment will be considered “at will”, which means that either GIANT STEPS TRAINING PROGRAMS, INC. or myself can end the employment relationship at any time for any reason.

Applicant Signature: Date: