Application for Employment

Application for Employment
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, please use a separate piece of paper. Please print, except for your signature.
Pronouns
Preferred name
Position:

Direct Support ProfessionalOther
Personal Information
Name

First NameMiddle NameLast Name
Address

House #, Apt #, Street

Street Address Line 2

CityState

ZIP Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
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.?

YesNo
Are you at least 18 years of age? (If hired, you may be required to submit proof of age.)

YesNo
We take precautions to assure the safety of the people we serve. Will you agree to a criminal background check?

YesNo
Driving is an essential function to the job. Do you have a current driver's license?

YesNo
Employment Availability
Date available to start work

MonthDayYear
Date
Availability

Full TimeRelief
DaysMidSwingOvernight
Position you are applying for
Recruitment Information
How did you hear about our job opening?

IndeedSocial Media (please specify below)Employment DepartmentBillboard/Sign/Vehicle LogosFriend - Who? (please specify below)Walk-Inlifempowered employee - Who? (please specify below)Other (please specify below)
Information from previous question
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 your resume to this application.
Name of Employer:
Telephone:
Address: (Including city & state)
Hire Date: (month & year)
Separation Date: (month & year)
Name of supervisor and title:
May we contact this employer for a reference?

YesNo
Job title at end of employment:
Job title at start of employment:
Duties and Responsibilities:
Reason for Leaving:
Name of Employer:
Telephone:
Address: (Including city & state)
Hire Date: (month & year)
Separation Date: (month & year)
Name of supervisor and title:
May we contact this employer for a reference?

YesNo
Job title at end of employment:
Job title at start of employment:
Duties and Responsibilities:
Reason for Leaving:
Name of Employer:
Telephone:
Address: (Including city & state)
Hire Date: (month & year)
Separation Date: (month & year)
Name of supervisor and title:
May we contact this employer for a reference?

YesNo
Job title at end of employment:
Job title at start of employment:
Duties and Responsibilities:
Reason for Leaving:
Have you ever applied for a position or been employed by lifempowered or Riverside Training Centers?

YesNo
If yes, please specify dates: From Date To Date
Position
Reason for leaving
Job Application revised: 09032025 ml

Living inspired, fully empowered!
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).
Name
Phone
Format: (000) 000-0000.
Years Known
Relationship
Name
Phone
Format: (000) 000-0000.
Years Known
Relationship
Name
Phone
Format: (000) 000-0000.
Years Known
Relationship
Pre-Employment Questionnaire
Do you have any experience with anything on the list below?

Personal Hygiene/Personal CareLifting/TransfersDiabetesG-TubesDiet ManagementASL (American Sign Language)OIS (Oregon Intervention System)Challenging BehaviorsMental IllnessTeamworkTraining/TeachingJob DevelopmentMedical TrainingSexual Disorder/Deviancy AdvocacySupervision/LeadershipPsychology
Bilingual
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 constitute cause for the denial of employment or immediate dismissal.
Applicant Signature
Date

MonthDayYear
Date
Please return your completed application to lifempowered, 105 Port Avenue, St. Helens, OR 97051 or email to jobinquiry@lifemp.org.

Job Application revised: 09032025 ml

Living inspired, fully empowered!
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 numbers 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

MonthDayYear
Date
5. Was the investigation:

SubstantiatedUnsubstantiatedInconclusive
Applicant Signature
Printed Name
Date

MonthDayYear
Date
Job Application revised: 09032025 ml

Living inspired, fully empowered!
Should be Empty:

Application for Employment

Instructions to Applicants

Personal Information

Employment Availability

Recruitment Information

Special Skills and Qualifications

Employment History

Professional References

Pre-Employment Questionnaire

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

Abuse Investigation Check