Employment form

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About You

Your Name

First Middle Last

Contact Information

Your Address

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Home Phone

Cell Phone

Work Phone

Best time to call

Best Number to Call

Home

Cell

Work

Preferred Method of Contact

What are you applying for?

Position Desired

Desired Hours/Week

Available Start Date

Full or Part Time?

Full Time

Part TIme

PRN

Shift Desired

AM

PM

NOC

Education

Name and Location of High School

Did you graduate?

Yes

No

If Yes, Date Graduated

Do you have Post High School Education?

Yes

No

College/University Name

College/University Location

Did you Graduate?

Yes

No

If Yes, Date Graduated

Degree(s) Obtained

Associate Degree

Undergraduate Degree

Graduate/Master's Degree

Employment History

Please list 3 present and past employers, starting with the most recent:

Employer 1

Phone

Address

Street Address Address Line 2 City State ZIP Code

Position

Salary

Start Date

Still Employed?

Yes

No

End Date

Supervisor

Title

Employer 2

Phone

Address

Street Address Address Line 2 City State ZIP Code

Position

Salary

Start Date

End Date

Supervisor

Title

Employer 3

Phone

Address

Street Address Address Line 2 City State ZIP Code

Position

Salary

Start Date

End Date

Supervisor

Title

Employer 4

Phone

Address

Street Address Address Line 2 City State ZIP Code

Position

Salary

Start Date

End Date

Supervisor

Title

References

Please provide three references that are not related to you.

Reference 1

First Last

Title

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Reference 2

First Last

Address

Street Address Address Line 2 City State ZIP Code

Title

Home Phone

Cell Phone

Work Phone

Reference 3

First Last

Title

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Licensure

If you are a licensed/certified professional, please complete the following:

Type of License:

State

Expiration Date

License Number

Describe any additional skills, training, or certification:

Applicants Statement

PLEASE READ THE FOLLOWING AGREEMENT CAREFULLY:

This institution does not discriminate in hiring on the basis of race, color, sex, citizenship, national origin, ancestry, veteran status, on the basis of age, physical, or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I understand and agree that, if I am employed, the following stipulations apply:

My initial employment will be on a 90-day introductory period.
Emergency conditions or staffing needs may require me to temporarily work on shifts/schedules other than the one(s) for which I’m applying. I hereby agree to such scheduling changes as directed by the department head or Administrator.
I’ll be required to abide by all rules and regulations of the facility. I understand that disregard for, or noncompliance with such rules and regulations, may be grounds for dismissal.

If employed, I will be required to complete an Employment Verification Form (1-9), and within three days, show satisfactory evidence of identity and eligibility for employment.

I have been informed that The Life Center will conduct a state-mandated criminal record check. I understand that I am required to successfully complete and pass a drug test. I also am aware that I need to pass a physical exam prior to hire, and thereafter according to state regulations.

I understand this employment application and any other Life Center documents, including employee handbooks, are not intended to create, and do not create, an employment contract between The Life Center and me. Your employment is at will. Just as you retain the right to terminate your employment at any time for any reason, The Life Center also retains the right to terminate your employment at any time for any reason.

I certify that the information I’ve provided on this application is true and correct to the best of my knowledge. I also understand if this application contains false or misleading information, or omission of important facts about myself, my employment may be terminated.

I confirm that I’ve read this statement, understand its meaning, and agree to all its stipulations.

Signed

Date

Phone

This field is for validation purposes and should be left unchanged.

Employment

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About You

Contact Information

What are you applying for?

Education

Employment History

References

Licensure

Applicants Statement

“Where Excellence is the Expectation.”

Contact Us

Phone Number

Location