Application for Employment

* Required fields are marked with an asterisk.

Date: 11/14/2026

Last Name: *

First Name: *

Middle Name:

Street: *

City: *

State:

Zip code:

Phone: *

Email: *

Date Available:

Position applying for:

Hourly rate expected:

Will you accept part-time (less than 40 hours/week)? *

Yes No

Do you have a valid Driver License? *

Yes No

If yes, for which state? *

If hired, can you show proof of authorization to work in the U.S.? (Verification will be required.): *

Yes No

Have you been employed here before? *

Yes No

If yes, give dates:

Education

High School or GED (please indicate which one)

Do you have a High School Diploma or GED? *

High School Diploma GED None

Name & Location: *

College/University

Name & Location:

Course of Study:

Graduate?

Yes No

Business/Vocational

Name & Location:

Course of Study:

Graduate?

Yes No

Graduate/other

Name & Location:

Course of Study:

Graduate?

Yes No

Training

Describe any other training (workshops/seminars) you have completed that will qualify you:

Employment Experience

Start with your present or last job and go back five (5) years, listing former employers. You may include military service assignments and volunteer activities.

1.

Employer: *

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving: *

Start date: *

Initial Pay Rate:

End date: *

Final Pay Rate:

Work Performed:

2.

Employer: *

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving: *

Start date: *

Initial Pay Rate:

End date: *

Final Pay Rate:

Work Performed:

3.

Employer:

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving:

Start date:

Initial Pay Rate:

End date:

Final Pay Rate:

Work Performed:

4.

Employer:

Phone:

Address:

Job Title:

Supervisor:

Reason for leaving:

Start date:

Initial Pay Rate:

End date:

Final Pay Rate:

Work Performed:

Professional References

Most recent supervisors or instructors are required. Do not list friends or relatives.

1.

Name/Title: *

Phone:

Company Name:

City:

State:

2.

Name/Title: *

Phone:

Company Name:

City:

State:

3.

Name/Title: *

Phone:

Company Name:

City:

State:

Ability

Can you perform all the essential functions of the position for which you are applying with or without a reasonable accommodation? *

Yes No

Please explain:

Supplemental Background Information

1. Have you ever been convicted for neglect or abuse, sexual abuse, or other acts of violence? *

Yes No

2. Are you currently being investigated for neglect or abuse of any kind? *

Yes No

3. Have you ever been terminated from any job for any reason other than a layoff? *

Yes No

Please provide dates and explanations for any "YES" answers to the last three questions:

Background Information Release

Have you ever been convicted of any criminal offense, either misdemeanor or felony? *

Yes No

If yes, please explain:

Do you have any tickets on your driving record? *

Yes No

If yes, please explain:

I give Quality Life Concepts my permission to conduct a background investigation. I hereby authorize any law enforcement agency and/or child protection agency to release any records they have regarding me to Quality Life Concepts. I understand that my potential employment is contingent upon these reports. A photocopy of this form is as valid as the original. *

I authorize Quality Life Concepts to obtain a copy of my motor vehicle record to evaluate my insurability or for other permissible uses related to my application. If I am hired for employment by Quality Life Concepts, I hereby authorize Quality Life Concepts to procure these records on a periodic basis or as deemed necessary to evaluate my continuing insurability. *

The following information is needed for the background check and the motor vehicle check.

Date of birth: *

Social Security Number:

Full name given at birth: *

Driver License Number:

Driver License State:

Agreement

I hereby authorize Quality Life Concepts, Inc. to inquire as to my record with any or all of my former employers with no liability arising therefrom. I hereby certify that all information above is true and complete to the best of my knowledge. I am aware that falsification or misrepresentation of required information is grounds for dismissal or disqualification from employment with Quality Life Concepts, Inc. *

I understand that if I am employed by Quality Life Concepts, Inc. the agency may change wages, benefits, and conditions at any time and that there is no guarantee of permanent employment. *

I understand if I am applying for a direct care provider position in Great Falls, I must attend Quality Life Concepts' pre-employment session which takes place every Tuesday at 10:00am at their office, located at 215 Smelter Avenue NE, Great Falls, MT 59404. *

Comments

Please list any additional comments or special qualifications you would like to be considered:

Application for Employment

Education

High School or GED (please indicate which one)

College/University

Business/Vocational

Graduate/other

Training

Employment Experience

1.

2.

3.

4.

Professional References

1.

2.

3.

Ability

Supplemental Background Information

Background Information Release

Agreement

Comments

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