Lifetime Recovery Employment Application

How did you hear about the position for which you are applying?*

Today's Date*

Date

Full Name*

First NameLast Name

Last 4 digits of Social Security Number*

Current Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Email Address*

example@example.com

Position for which you are applying*

Date available for work*

Date

Minimum salary requirement*

Type of hours are you available to work*

Full-timePart-timeTemporary

If part-time, specify what hours and days you are available

Are you subject to any type of agreement with a current of former employer that would restrict your ability to work at the position to which you have applied (e.g., non-compete, confidentiality, non-disclosure)?*

YesNo

Do you graduate from high school or receive your GED?*

YesNoAttended, but did not graduate

School Name: school name*
City & State: city & state*
Degree/Diploma/Major of Study: degree*

Did you graduate from Trade School?*

YesNoAttended, but did not graduate

Trade School Name: school name*
City & State: city & state*
Degree/Diploma/Major of Study: degree*

Did you graduate from a College/University?*

YesNoAttended, but did not graduate

College/University Name: school name*
City & State: city & state*
Degree/Diploma/Major of Study: degree*

Did you graduate from Graduate School?*

YesNoAttended, but did not graduate

College/University Name: school name*
City & State: city & state*
Degree/Diploma/Major of Study: degree*

List the area of study or degree/diploma received from an unaccredited college, as well as any other education, training, special skills or certificates/licenses that you have related to the position you are applying towards.

Professional License or Certifications (please include issuing agency, state issued & expiration date)

List any machines, equipment or software programs you are qualified and experienced in using.

List any languages you speak fluently *

List any languages the you read/write fluently *

If you are applying for a position involving driving a motor vehicle as part of your duties, please Indicate whether you have a valid driver's license.*

YesNo

Can you verify you are authorized to work in the United States?*

YesNo

Are you 16 years old or over?*

YesNo

Were you previously employed by Lifetime Recovery?*

YesNo

If yes, please give previous start date:

Date

If yes, please give end date:

Date

Can you perform the essential functions of the position you are applying for?*

YesNo

List any relatives you have working at Lifetime Recovery.

Employer 1 Information

Name of Employer*

Type of Business*

Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Phone Number*

Please enter a valid phone number.

Name & Title of Supervisor*

Job Title*

Type of Employment*

Part-timeFull-time

May we contact employer?*

YesNo

Employment Start Date*

Date

Employment End Date*

Date

Last Salary*

Brief Description of Duties*

Reason For Leaving*

Employer 2 Information

Name of Employer*

Type of Business*

Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Phone Number*

Please enter a valid phone number.

Name & Title of Supervisor*

Job Title*

Type of Employment*

Part-timeFull-time

May we contact employer?*

YesNo

Employment Start Date*

Date

Employment End Date*

Date

Last Salary*

Brief Description of Duties*

Reason For Leaving*

Employer 3 Information

Name of Employer

Type of Business

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Phone Number

Please enter a valid phone number.

Name & Title of Supervisor

Job Title

Type of Employment

Part-timeFull-time

May we contact employer?

YesNo

Employment Start Date

Date

Employment End Date

Date

Last Salary

Brief Description of Duties

Reason For Leaving

Please include Name, Occupation, Relation and Phone number for each reference.

Please include any other information you think that would help you better qualify for this position such as work experience, articles/books, activities, honors achieved, and any other. Please do not include information that includes age, sex, sexual orientation, race, religion, color, national origin, or disability.

Agreement (Please read the following information very carefully).

I hereby affirm that the information provided on this application (and included resume, if any) is true and complete to the best of my knowledge, I also agree that falsification, or leaving out required information, requested in this application or in the application process may disqualify me from further consideration for employment and may be cause for dismissal if discovered at a later date.

I authorize all people listed above, and on the resume, to give Lifetime Recovery any and all information concerning my previous employment and education and any pertinent information they have, personal or otherwise, and release all parties, and Lifetime Recovery from liability for an damage that may result from furnishing information to Lifetime Recovery.

If employed, I agree to abide by, and sign for, the policies and procedures, which include anti-harassment. I further understand that my employment can be terminated, with or without cause or notice, at the direction of Lifetime Recovery or myself. I further understand that no manager or representative of Lifetime Recovery has any authority to enter into agreement, oral or written on behalf of Lifetime Recovery, for a term of employment or to make assurance or promise of continued employment.

I understand and agree that, subject to applicable law, I might be required to take an alcohol or drug screening test. I hereby give my voluntary consent for a urine or blood sample to be collected from me and submitted for testing. I also consent to the release of the results to Lifetime Recovery. I understand that a positive drug or alcohol result may preclude my employment.

The needs of the employer may make the following conditions mandatory: overtime, shift work, rotating work schedules, or a work schedule other than Monday through Friday. I accept these conditions of employment.

Applicant Full Name

Last 4 digits of Social Security Number

Date Submitted

Date

Applicant's Signature

Lifetime Recovery Employment Application

As part of the application process Lifetime Recovery will conduct background checks on applicants.

Education and Training

Work History

Employer 1 Information

Employer 2 Information

Employer 3 Information

Business References