Employment Application Form

Employment Application

An Equal Opportunity Employer
LIVING UNLIMITED WILL PROVIDE REASONABLE ACCOMMODATION TO THE KNOWN DISABILITIES OF APPLICANTS AND EMPLOYEES, UNLESS TO DO SO WOULD POSE AN UNDUE HARDSHIP. PLEASE FEEL FREE TO LET US KNOW IF YOU NEED AN ACCOMMODATION TO COMPLETE THE APPLICATION PROCESS OR TO PERFORM ANY ESSENTIAL ELEMENTS OF THE POSITION SOUGHT.

Applicants are considered for all positions, and employees are treated during employment, without regard to race, color, religion, sex, national origin, age, disability or any other prohibited basis of discrimination, as provided under applicable state and federal law.
Name:*

First NameMiddle NameLast Name
Preferred Name/Pronouns*
Former Last Name*
Phone Number:*
E-mail Address:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Township*
Position to which you are applying for:*
Work preference:*

Full-timePart-time
PLEASE DO NOT WRITE SEE RESUME

Employment History*

	Company Name	Address/ Phone #	Dates Employed From/To	Job Title	Salary	Reason for Leaving	May We Contact Yes/No	Supervisor Name/ Phone #
1
2
3
4
5

Please list reason(s) for any gaps in employment.*
Upload Resume:*

Cancelof

Education*

	Name	Year Graduated	Cert./ Diploma/ Degree
High School
College
Graduate School
Other

Have you been employed here before?*

YesNo
Do you have a valid driver's license?*

YesNo
Do you have access to a car and can you use it for work?*

YesNo
Rehabilitation Specialist and Music Therapist positions are community-based and require a significant amount of travel as part of their workday. Are you willing to travel for work?*

YesNoI am not applying to the Rehabilitation Specialist or Music Therapist position
Have you ever been convicted of a felony or misdemeanor that has not been sealed, expunged or annulled?*

YesNo
If yes, explain when and the nature of the offense.
Have you lived in Pennsylvania for the last two years?*

YesNo
List any languages you are fluent in other than English
Have you provided 6 or more months of volunteer or paid services to older adults or those with physical disabilities?

YesNo
Are you authorized to work in the United States?*

YesNo
How were you referred to us?*

EmployeeNewspaper AdFacebookLiving Unlimited WebsiteIndeed
If referred by an employee, please list the employee's name:
Salary expectation
Professional References Please list three (3) professional references with their active email addresses (Job-related references preferred e,g, Manager, Supervisor etc).
Professional Reference 1:*

First NameLast Name
Phone Number*
Email*
example@example.com
Years Known:*
Professional Reference 2:*

First NameLast Name
Phone Number*
Email*
example@example.com
Years Known:*
Professional Reference 3:*

First NameLast Name
Phone Number*
Email*
example@example.com
Years Known:*
I represent that the above statements and answers are true and complete to the best of my knowledge and belief. Any misrepresentation or falsified statements on this application may be considered sufficient grounds for dismissal. I hereby authorize Living Unlimited to obtain a criminal background check as part of the employment process. I understand that unfavorable information obtained in response to the criminal background check may constitute reasonable grounds for withdrawal of an employment offer or termination. Further, the interviewing team has my authorization to contact the references I have provided. I also understand in the event of any employment opportunity offered, I shall become an employee at will under the terms and conditions of the company policies. I am aware that Living Unlimited has a smoke-free policy in effect for all of its corporate offices.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Employment Application

PLEASE DO NOT WRITE SEE RESUME