Application For Employment With lifempowered

APPLICATION FOR EMPLOYMENT
Position *

Direct Support Professional Other
Instructions to Applicants
Answer each question completely. All fields must be completed. No action will be taken on incomplete applications. If more room is needed, you may add a separate document or piece of paper. (Hardcopy) Please print, except for your signature.
Personal Information
Name *

First Name Middle Name Last Name
What are your preferred pronouns? (Examples: he, she, them, her, him, they)

Pronoun Preference 1 Pronoun Preference 2 Pronoun Preference 3
Cell Phone
Alternate Phone
Email Address *
Address (house #, apt #, street) *

Address

Street Address Line 2

City State

Zip Code
All employees must be legally authorized to work in the United States. If hired, can you furnish proof you are eligible to work in the U.S.? *

Yes No
Are you at least 18 years of age? (If hired, you may be required to submit proof of age). *

Yes No
Driving is an essential function of the job. Do you have a current and valid driver's license? *

Yes No
Driver's license number:
State issued
Employment Availability
Date available to start work

Month Day Year
Date
Work preference

Full Time Relief Days Swing Overnight
Recruitment Information
How did you hear about our job opening? Please check one only. *

Facebook State Job Listings Twitter Newspaper Instagram ImpactOregon TikTok Walk-In Indeed Friend lifempowered employee Craigslist Other
If you chose "Friend", please list their name
If you chose "lifempowered employee", please list their name
Education
High School/GED Program Name of School
Did you graduate? *

Yes No
College University/Technical School Name of school
Did you graduate?

Yes No
Number of years completed?
Degree/Major?
Special Skills and Qualifications
List relevant job related skills, training or qualifications you possess:
List any professional groups to which you belong. Omit organizations that reveal race, ethnicity, religious, or political affiliation.
Employment History
Starting with your current or most recent employer, list all work experience for the last seven years. If you have not worked for the last seven years, list your most recent employment, regardless of how long ago it was. Include all jobs (full time, part-time, volunteer work, internships, active military, or national service experiences You may attach/submit your resume to/with this application. (jobinquiry@lifemp.org
1 Name of Employer
1 Telephone
1 Address (including city and state)
1 Hire date: (month and year)
1 Separation date: (month and year)
1 Name of supervisor and title
1 Can we contact this employer for reference?

Yes No
1 Job title at end of employment
1 Job title at start of employment
1 Duties and responsibilities
1 Reason for leaving
2 Name of Employer
2 Telephone
2 Address (including city and state)
2 Hire date: (month and year)
2 Separation date: (month and year)
2 Name of supervisor and title
2 Can we contact this employer for a reference?

Yes No
2 Job title at end of employment
2 Job title at start of employment
2 Duties and responsibilities
2 Reason for leaving
3 Name of Employer
3 Telephone
3 Address (including city and state)
3 Hire date: (month and year)
3 Separation date: (month and year)
3 Name of supervisor and title
3 Can we contact this employer for a reference?

Yes No
3 Job title at end of employment
3 Job title at start of employment
3 Duties and responsibilities
3 Reason for leaving
Have you ever applied for a position, or been employed by lifempowered or Riverside Training Centers? *

Yes No
If you answered "Yes", please specify date from:
If you answered "Yes", please specify date to:
Position
Reason for leaving
Professional References
Please provide the names and telephone numbers of at least three individuals who can speak to your work history who are NOT RELATED TO YOU (previous supervisors preferred).
1 Name
1 Telephone
Please enter a valid phone number.
1 Years Known
1 Relationship
2 Name
2 Telephone
Please enter a valid phone number.
2 Years Known
2 Relationship
3 Name
3 Telephone
Please enter a valid phone number.
3 Years Known
3 Relationship
Pre-Employment Questionnaire
Do you have any experience with anything on the list below?

Personal Hygiene/Personal Care Teamwork Lifting/Transfers Training/Teaching G-Tubes Job Development Diet Management Medical Training Sexual Disorder/Deviancy Advocacy Supervision/Leadership ASL (American Sign Language) Psychology OIS (Oregon Intervention System) Mental Illness Challenging Behaviors CPR/First Aid Addiction Issues AAC (Augmentative and Alternative Communications) Social Networking Assistive Technology General Computer Skills Nutrition/Menu Planning Event Planning Person Centered Thinking Virtual Activities/Chat Computer Software/Programs: Diabetes
If you have experience with computer software/programs, please list them
Are you bilingual? *

Yes No
If so, in which language(s)?
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

lifempowered is an equal opportunity employer. lifempowered promotes a harassment-free workplace and does not discriminate in employment in regard to race, color, religion, national origin, citizenship status, ancestry, age, gender, sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service.

Neither the completion of this application, nor any other part of my consideration for employment, establishes any obligation for lifempowered to hire me. If I am hired, I understand that either lifempowered or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of lifempowered has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to lifempowered true and complete information on this application. No requested information has been concealed. I authorize lifempowered to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will consititute cause for the denial of employment or immediate dismissal.
Applicant Signature *

Clear
Date *

Month Day Year
Date
Please electronically submit your completed application or return a hardcopy to lifempowered, 105 Port Avenue, St Helens, OR 97051 or email to jobinquiry@lifemp.org
Abuse Investigation Check
Please read the following statement carefully and complete as necessary. If your answer to question 1 is "No", please proceed to signature section.
1 Have you ever been named as an alleged perpetrator in an abuse investigation involving children and/or adults? *

Yes (please complete questions 2-5) No (please sign form and return with application)
2 County where investigation took place
3 Type of alleged abuse
4 Approximate date of investigation
5 Was the investigation

Substantiated Unsubstantiated Inconclusive
Applicant Signature *

Clear
Printed Name *
Date *

Month Day Year
Date
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APPLICATION FOR EMPLOYMENT

Instructions to Applicants

Personal Information

Employment Availability

Recruitment Information

Education

Special Skills and Qualifications

Employment History

Professional References

Pre-Employment Questionnaire

Abuse Investigation Check