LTS Employment Application

Employment Application

Po Box 193 North Haverhill, NH 03774 (603)-787-6656
Applicant Information
Today's Date

MonthDayYear
Date
Name:*

First NameMiddle InitialLast NameSuffix
Other Names by which you have been known (if any)

First NameMiddle InitialLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Social Security #*

000000000
Birth Date*

MonthDayYear
Home Phone

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
E-mail Address:*
Emergency Contact*

NamePhoneE-Mail
Relatives Currently or Formerly Employed at LTS
First NameMiddle InitialLast Name
First NameMiddle InitialLast Name

Education History

Type a question

	Name and Address Of School	Course Of Study	Years Completed	Diploma/ Degree
High School
Undergraduate College
Graduate Professional
Other

Describe and specialized training.
example: apprenticship, skills and/or extra-curricular activities.
Other Qualifications:
Summarize special job-related skills and qualifications acquired from employment or other services.
Upload Resume

Browse Files

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Employment History

Start with your current or most recent employer and work backwards regarding all former employers.
Current or Most Recent Employer:*
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities
Hours worked per Week Reason for Leaving
May we Contact this Employer?*
Next Recent Employer:
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities
Hours worked per Week Reason for Leaving
May we Contact this Employer?
Next Recent Employer:
Name of Employer
Address
City, State, Zip
Last Position You Held:
Immediate Supervisor(s)
Phone Number(s)
Dates of EmploymentMost Recent Salary or Hourly Rate
Job Title and Responsibilities
Hours worked per Week Reason for Leaving
May we Contact this Employer?
References

Please list two references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Click to edit
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Military Service
Branch
From

MonthDayYear
Date
To

MonthDayYear
Date
Rank at Discharge
Type of Discharge
If other then honorable please explain:

1. Can you provide proof of eligibility to become employed in the United States?*
If no on #1, are you able to provide such proof which will be required upon employment if you are offered a position?
2. If you are under the age of 18, can you provide required proof of your eligibility to work?*
3. Have you ever filed an application for employment with us before?*
If Yes, set forth dates of your application:
4. Are you currently employed?*
If currently employed and you do not wish for us to contact your employer, please set forth the reasons why:
5. Are you currently on layoff status and subject to recall?*
6. Do you have adequate transportation to meet travel requirements of the job?*
7. Do you have a current valid drivers license?*
If yes, please state the following:
Issuing StateExpiration Date
8. Are you able and willing to travel for this job if travel is necessary?*
9. Are you aware of any reason that may restrict your ability to perform the essential functions of the job for which you are making application?*
If yes, please explain and describe what accommodations might be necessary:
10. Have you ever been terminated or forced to resign from your employment with any employer?*
If yes, please explain:
11. Have you ever been convicted of a felony?*
If yes, please explain including the employer for whom the security clearance was denied, the date on which such security clearance was denied and the reason that such security clearance was denied:
12. Have you ever been convicted of a crime including any driving and/or alcohol related offenses?*
If yes, please explain:

Disclaimer & Signature
I give Life Transition Services, LLC the right to investigate, by any available public or private investigation source, all references and to secure any additional information about me, if job related, including complete criminal records check and department of Motor Vehicle License check and if hired by New Hampshire contracting school, employment will be contingent upon finger printing and compliance with NH DOT pupil transport regulations. I hereby release from liability Life Transition Services, LLC and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

Life Transition Services, LLC is an Equal Opportunity Employer. Life Transition Services, LLC does not discriminate in employment and the answer to any question on this application for employment is not used for the purpose of limiting or excluding any applicant’s consideration for employment on any basis prohibited by local, state or federal law.

It is understood and agreed upon that any misrepresentation by me in this application for employment will result in cancellation of this application for employment and/or separation from Life Transition Services, LLC if I have been employed. To the best of my knowledge, all information included in this application for employment is accurate and correct.
Electronic Signature *

First NameLast Name
Should be Empty:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Mornings
Afternoons
Evenings
Not Available

	Yes	No
Are you capable of performing in a reasonable nabber war us expected fir Home Providers?
Do you agree with our mission statement ?
Do you understand how you would be compensated ?
Do you understand that being a Home Provider for Life Transition Services LLC is a contractual position and you are self-employed?

	Yes	No
Carring for DD Client in your own home or apartment ?
Carring for DD Client in client's home or apartment as a Personal Care Attendant

Employment Application

Applicant Information

Relatives Currently or Formerly Employed at LTS

Education History

Employment History

References

Reference 1

Reference 2

Military Service

Home Care Provider

Disclaimer & Signature