Lifegate Health - Job Application Form

Application for Employment
Personal Information
Full Legal Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
example@example.com
Cell Phone*
Other Phone
Are you a U.S. Citizen or Alien authorized to work in the United States:*

YesNo
Have you ever been employed by Life Gate Healthcare Services, Inc?*

YesNo
If yes, which office?
Position Held
How were you referred to the organization?

Licenses
License/Certification*
List any licenses (including driver’s), certificates, registrations or professional associations which relates to, or is a requirement of, the position for which you are applying.
Employment History

Employment History - Please give accurate, complete full-time and part-time employment record, beginning with your present or most recent employer. You may attach your resume.
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Supervisor's Name *
Position*
Ending Salary*
Dates of of Employment*
Reason for leaving?*
Job Responsibilities*
May we contact this employer for a professional reference?*

YesNo

Employment History #2

Employment History (Please give accurate, complete full-time and part-time employment record, beginning with your present or most recent employer. You may attach your resume.
Company Name
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Supervisor's Name
Position
Ending Salary
Dates of Employment
Reason for leaving?
Job Responsibilities
May we contact this employer for a professional reference?

YesNo

Professional References

Please list a minimum of three (3) professional references. Do NOT list personal references
Reference #1
Name*

First NameLast Name
Title*
Company Name & Address*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Reference #2
Name

First NameLast Name
Title
Company Name & Address
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Reference #3
Name

First NameLast Name
Title
Company Name & Address
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Have you ever been terminated from, or discipined by, a previous empoyer for abuse or neglect*

YesNo
If yes, please explain
Have you ever been convicted of a crime which has bot been annulled, expunged, or sealed by a court?*

YesNo
If yes, please explain

The information provided on this Application for Employment is true, correct, and complete. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or termination from employment if I am subsequently employed.

I give Life Gate the right to investigate all references and to secure additional information about me, including criminal background clearance, child abuse clearance, FBI clearance, motor vehicle records, etc. as deemed necessary and appropriated by the company for the position(s) for which I am applying. I hereby release from liability Life Gate Healthcare services, INC. and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

Life Gate is an Equal Opportunity Employer.
Please upload your resume

This is not mandatory.
Cancelof
Please verify that you are human*
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Application for Employment