Full Name:
Street Address:
City:
State:
 ZIP:
Email Address:
Home Phone:
Mobile Phone:
Social Sec. #:

Are you seeking a long-term position?:
 Yes No
Are you seeking only a seasonal/holiday position?:
 Yes No
Do you have a valid Arizona driver's license?:
 Yes No
Do you maintain a reliable and fully insured vehicle?:
 Yes No
Have you been convicted of any traffic offenses within the last five years?:
 Yes No
Have you ever been convicted of a misdemeanor or felony offense?:
 Yes No
Have you had any credit "charge offs" or bankruptcies within the last five years?:
 Yes No
Would you be comfortable giving animals injections?:
 Yes No

*What animals do you have experience with?

*What animals are you comfortable with?



EDUCATION

Name of high school:
City/State
Dates attended:
Graduated:
 YES- NO-

GED in lieu of HS diploma
  
Name of GED institution:
Address (including zip code):
Date GED received:
Please list any and all secondary education.
Name of School:
Specialty:
City/State
Dates attended:
Graduated:
 YES- NO-
Type of degree (if applicable):
Name of School:
Specialty:
Dates attended:
Graduated:
 YES- NO-
Type of degree (if applicable):
Name of School:
Specialty:
City/State
Dates attended:
Graduated:
 YES- NO-
Type of degree (if applicable):

EMPLOYMENT
Most Recent Employer:
Address:
Supervisor:
Telephone Number:
Position/Duties:
Dates of employment:
Reason For Leaving:
Can we call for references:
 YES- NO-
If not, please state why:
2nd Most Recent Employer:
Address:
Supervisor:
Telephone Number:
Position/Duties:
Dates of employment:
Reason For Leaving:
Can we call for references:
 YES- NO-
If not, please state why:

3rd Most Recent Employer:
Address:
Supervisor:
Telephone Number:
Position/Duties:
Dates of employment:
Reason For Leaving:
Can we call for references:
 YES- NO-
If not, please state why:

AVAILABILITY
Morning
Any
M
Tu
W
Th
F
Sa
Su
Mid-Day
Any
M
Tu
W
Th
F
Sa
Su
Evening
Any
M
Tu
W
Th
F
Sa
Su
Overnights
Any
M -T
T-W
W-T
T-F
F-S
S-S
S-M
Live-Ins
Any
M -T
T-W
W-T
T-F
F-S
S-S
S-M
Boarding
Any
M -T
T-W
W-T
T-F
F-S
S-S
S-M


REGION
Please list zip codes in which you are willing to work. Refer to Zip Code map for reference.

REFERENCES
Please provide contact information for five individuals who can attest to your reliability, trustworthiness, and suitability in caring for animals. Feel free to send letters of reference – particularly from those persons whose animals you cared for while they were away.
Name:
Address:
Telephone:
Remarks:
Name:
Address:
Telephone:
Remarks:
Name:
Address:
Telephone:
Remarks:
Name:
Address:
Telephone:
Remarks:

MISC.
How did you hear about ACS opportunities?
Do you know anyone presently or previously employed through ACS and if so, who?
What is the minimum amount of money that you wish to make weekly through ACS?
How many hours do you wish to work each week?
Do you currently have another source of income and if so, What is that source of income?
Will you be maintaining that source of income if affiliated with ACS?
Describe your short-term and long-term goals. How does this position fit into meeting those goals?
What things should we know about you that make you especially suited for this position?

Certification of Above Information and Authorization for Release of Information

By submitting this completed questionnaire to ACS, you hereby:

I. certify that the foregoing is true and correct to the best of your knowledge;

II. authorize All Critters Sitter LLC, its agents and its subcontractors, to obtain and review any and all information relevant to your experience, education, work habits, financial status, criminal and civil court record (if any), and character;

III. authorize, without reservation, any person, organization, company, and governmental body to furnish any and all information, as described in paragraph II, to All Critters Sitter LLC, its agents and subcontractors thereof.
Accept-
Decline-