LifeSpan Resources

Promoting Independent Living for People of all Ages.

DATE*

Date

DESIRED POSITION*

Date Available to Work*

Date

POSITION APPLIED FOR*

Referred by

INSTRUCTIONS: Please read carefully. Every item on this form must be answered to the best of your ability. Please print and use a pen. Your qualifications will be carefully reviewed and you will be given thorough consideration for any suitable vacancy. Upon employment, this application will become part of your permanent record with This Employer. Keep this in mind as you complete it. Special Note: You are not required to supply any information that is prohibited by Federal, State, or Local law. We are an Equal Opportunity Employer. This Employer does not discriminate on the basis of race, color, religion, sex, national origin, citizenship, age, marial status, or disability. You may request assistance in completing this application.

First*

M.I.*

Last*

Telephone Number*

Street*

Box

City*

ST*

Zip*

Previous Address

Social Security Number*

If younger than 18, state age here:

Are you legally entitled to work in the United States?*

YesNo

Have you ever been convicted of a felony?*

If yes, explain

Have you ever been convicted of a moving traffic violation?*

YesNo

If yes, list all here

Have your driving privileges ever been revoked or suspended?*

YesNo

If yes, list all

Do you have a Commercial driving license?

YesNo

Education - High School (Name and Address)*

Did you graduate?*

If no, last grade completed

G.E.D. Obtained? If Applicable

Grade Average

Colleges (Name and Address)*

Colleges (Name and Address) - if more than one

Did you graduate?*

If no, number of hours completed

Grade Point Average*

Degree*

Major*

Minor

If attending, date of graduation

Date

Other Education

Awards, Honors, Leadership Roles

List service in U.S. Military: From

From

to

Branch

Rank at Discharge

Military experience that may be applicable

MOS

List here all of the equipment with which you have experience and training. (Examples: Computers, Computer Programs, Copiers, Phones, etc.)*

Are you willing to relocate?

If yes, state location preferred

Salary Expected per hour*

Number of hours you are available per week? (40 hours is normal)*

Type of Employment sought:*

Which of these times are you available?*

DaysNightsWeekendsHolidays

Check below if anytime will work during business hours*

Anytime

Time Beginning

Time Ending

Are you able and willing to perform the essential functions of the job for which you are applying, including travel, if necessary?*

yesno

If no, indicate reason:

need different hoursneed different daysneed more training

Other, (explain)

List below all present and past employment, beginning with your most recent employer

Employer (Most Recent)*

Starting Salary Per Hour *

Last Salary Per Hour*

Address*

Kind of Business*

Supervisor*

Job Title*

Reason for leaving*

QuitDischargeRetiredCurrently Employed Here

From*

To*

Type Present if currently employed

For Job Reference, call (Name)*

at (Telephone number)*

Please do not call this employer

Please do not call employer

Why should we not call this employer?

Employer #2

Starting Salary Per Hour

Last Salary Per Hour

Address

Kind of Business

Supervisor

Job Title

Reason for leaving

QuitDischargeRetiredCurrently Employed Here

From

To

For Job Reference, call

at (Telephone Number)

Please do not contact this employer

Why should this employer not be contacted?

Employer #3

Starting Salary

Last Salary

Address

Kind of Business

Supervisor

Job Title

Reason for leaving*

QuitDischargeRetired

From*

To*

For Job Reference, Please Call*

at telephone number*

Please do not contact this employer

Why should this employer not be contacted?

In the following space, please describe briefly why you are applying for this position*

The facts as stated on this application are true and correct. I understand that, if employed, false statements on this application may cause my immediate dismissal. Iauthorize such background and personal reports as deemed necessary to verify that the information I have supplied is true and accurate and to determine my fitness for this job and hold harmless those who have the responsibility to develop such a report. A copy of this authorization is as valid as the original. I understand that I may be required to work overtime as a condition of being employed. In consideration of my employment, I agree to conform to the rules and regulations for employees. | understand I am an employee at will, and that this application is not a contract of employment with This Employer and that my employment and compensation can be terminated, with or without cause, at anytime, at the option of either This Employer or me. I understand that no representative of This Employer has any authority to enter into any verbal agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and that no document, policy or practice of This Employer may change the foregoing unless it is expressly titled "Employment Agreement" and signed by both myself and an officer of This Employer. I understand that I may be required to submit to a pre-employment, and cost-employment test for fitness and/or substance abuse, if not prohibited by law. Upon separation of employment, I authorize This Employer to withhold from my final pay check any monies owed to them by me.

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/ national guard, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

DATE*

Date

SIGNATURE*

WELCOME TO LifeSpan Resources

LifeSpan Resources

AREA 14 AGENCY ON AGING

APPLICATION FOR EMPLOYMENT

PERSONAL

MILITARY

GENERAL EMPLOYMENT INFORMATION

Indicate hours you are available to work on the following days (or check anytime, if you have no restrictions) Normal working time is 8 a.m. - 4:30 p.m., Monday - Friday

Monday - Friday (Please indicate below on a beginning time and an ending time preference or click "anytime"

Dates Employed

Dates Employed

Dates Employed