Lifeline Home Healthcare
6203 Constitution Drive
Fort Wayne, Indiana, 46804
Phone: (260) 443-5102
Employment / Job Application
PERSONAL INFORMATION
FULL NAME:
DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CITY:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
STATE:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ZIP CODE:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-MAIL:
example@example.com
PHONE:
Format: (000) 000-0000.
SOCIAL SECURITY NUMBER (SSN)-------------
DATE AVAILABLE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DATE OF BIRTH:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DESIRED PAY: $
HOUR
SALARY
POSITION APPLIED FOR:
EMPLOYMENT DESIRED:
FULL-TIME
PART-TIME
SEASONAL
EMPLOYMENT ELIGIBILITY
ARE YOU A U.S. CITIZEN?
*
YES
NO
*IF NO, ARE YOU ALLOWED TO WORK IN THE U.S.?
YES
NO
HAVE YOU EVER WORKED FOR THIS EMPLOYER?
*
YES
NO
*IF YES, WRITE THE START AND END DATES:
HAVE YOU EVER BEEN CONVICTED OF A FELONY?
*
YES
NO
Page 1
Back
Next
*IF YES, PLEASE EXPLAIN:
Back
Next
EDUCATION
HIGH SCHOOL:
CITY / STATE:
FROM:
TO:
GRADUATE?
YES
NO
DIPLOMA:
COLLEGE:
CITY / STATE:
FROM:
TO:
GRADUATE?
YES
NO
DEGREE:
OTHER:
CITY / STATE:
FROM:
TO:
DEGREE:
OTHER:
CITY / STATE:
FROM:
TO:
EMPLOYMENT HISTORY
EMPLOYER #1:
E-MAIL:
example@example.com
PHONE:
Format: (000) 000-0000.
ADDRESS:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
STARTING PAY:
HOUR
SALARY
ENDING PAY:
HOUR
SALARY
JOB TITLE:
RESPONSIBILITIES:
STARTING DATE:
ENDING DATE:
REASON FOR LEAVING:
Page 3
Back
Next
MILITARY SERVICE
ARE YOU A VETERAN?
YES
NO
BRANCH:
RANK AT DISCHARGE:
STARTING DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ENDING DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
TYPE OF DISCHARGE:
IF NOT HONORABLE, PLEASE EXPLAIN:
BACKGROUND CHECK CONSENT
IF ASKED, WOULD YOU CONSENT TO A BACKGROUND CHECK?
YES
NO
DISCLAIMER
The applicant understands that this is an Equal Opportunity Employer who is committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered.
I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.
SIGNATURE
DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PRINT NAME
Page 4
Preview PDF
Submit
Should be Empty: