Employment Application



Thank you for your interest in a position with L.I.F.E. Inc. Please fill out this application as completely as possible. Not doing so will delay or prevent us from reviewing your application.


Demographic Section


Full Name:

Street Address:   Apt / Suite:

City:   State:   Zip Code:

Contact Telephone Number: ( ) -

Email Address:

Previously applied with L.I.F.E. Inc.:   Yes   No  

If yes, please approximate date:

Position Desired:   Pay Desired: $ . per hour

Are you under the age of 18:  Yes   No    Are you eligible for employment in the USA: Yes No
Please note that employment is subject to verification of minimum legal age and legal employment eligibility

How you learned of our organization:
Available to Start:

Other Special Skills or Training:

Is there any information about use of another name, needed to fully check your work record:  Yes   No  

If yes, please explain below:

Former Address Section

Please list the last two (2) addresses you have resided in the last ten (10) years

First Previous Address

Street Address:   Apt / Suite:

City:   State:   Zip Code:

Beginning:      Ending:

Second Previous Address

Street Address:   Apt / Suite:

City:   State:   Zip Code:

Beginning:      Ending:

Educational Section

Please list below the institutions where you have been educated, beginning with the most recent

Most Recent

Institution Type:    Institution Name:

Institution Location:   Years Completed:

Did you graduate from this institution:  Yes   No      Did you earn a degree:  Yes   No


Next Most Recent (if applicable)

Institution Type:    Institution Name:

Institution Location:   Years Completed:

Did you graduate from this institution:  Yes   No      Did you earn a degree:  Yes   No


Third Most Recent (if applicable)

Institution Type:    Institution Name:

Institution Location:   Years Completed:

Did you graduate from this institution:  Yes   No      Did you earn a degree:  Yes   No

Previous Employment Section


Please provide an accurate and complete full-time and part-time employment record, beginning with the most recent

Most Recent Employer

Company Name:   Phone: ( ) -

Street Address:

City:   State:   Zip Code:

Beginning:      Ending:

Supervisor:

Starting Pay: $ . per hour                         Ending Pay: $ . per hour

Job Title:

Job Description:

Reason for Leaving:


Next Most Recent Employer

Company Name:   Phone: ( ) -

Street Address:

City:   State:   Zip Code:

Beginning:      Ending:

Supervisor:

Starting Pay: $ . per hour                         Ending Pay: $ . per hour

Job Title:

Job Description:

Reason for Leaving:


Third Most Recent Employer

Company Name:   Phone: ( ) -

Street Address:

City:   State:   Zip Code:

Beginning:      Ending:

Supervisor:

Starting Pay: $ . per hour                         Ending Pay: $ . per hour

Job Title:

Job Description:

Reason for Leaving:

Reference Section

Please provide two (2) professional references we could contact who are familiar with your work

Reference One

Name:   Company:

Job Title:   Phone: ( ) -


Reference Two

Name:   Company:

Job Title:   Phone: ( ) -


L.I.F.E. Employee References

Please list any friends or relatives that currently or previously worked for L.I.F.E. Inc.

Name:   Job Title:

Location:   Current L.I.F.E. Employee:  Yes   No




Name:   Position:

Location:   Current L.I.F.E. Employee:  Yes   No




Name:   Position:

Location:   Current L.I.F.E. Employee:  Yes   No


Employment Section

Type of Hours:  Full-Time   Part-Time          Number of Hours: per week

Shifts:  First (8:00 am - 3:00 pm)    Second (3:00 pm - 10:00 pm)    Third (10:00 pm - 8:00 am)  

Have you ever been terminated from a job:  Yes   No

If yes, please explain below:

Are there any additional past or present employers you did not list on this application:  Yes   No
If yes, how many:    Would you be interested in applying for a subbing position:  Yes   No
If employed in a subbing position capacity you earn employment experience that is taken into account should you later apply for a full or part-time position

Will you be able to attend monthly staff meetings:  Yes   No

If no, please explain below:

Background Section

Have you ever been convicted of child abuse or of a felony for sexual or physical assault:  Yes   No

If yes, please explain below:

Do you have a current and valid driver's license:  Yes   No
License State:
License Expires On:

Do you have a clean driving record:  Yes   No

If no, please explain below:

Driving Violation Section

Please list any motor vehicle violations you have incurred in the last three (3) years

Violation Date:        Violation Type:

Violation Fault:   Violation has been resolved:  Yes   No




Violation Date:        Violation Type:

Violation Fault:   Violation has been resolved:  Yes   No




Violation Date:        Violation Type:

Violation Fault:   Violation has been resolved:  Yes   No




Violation Date:        Violation Type:

Violation Fault:   Violation has been resolved:  Yes   No

Essential Job Functions

Essential job functions for some positions at our agency may include (but not limited to) the following:

• Chauffeured Driving
• Food Preparation
• Heavy Lifting
• Behavioral Intervention Procedures
• Administration of First Aid/CPR

As far as you know, would you be able to perform all of the identified essential job functions with or without accommodations
 Yes   No



  I hereby declare the information provided by me in this Application for Employment is true, correct, and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered grounds for dismissal. I understand that a condition of employment is a clean driving record and a valid driver’s license. Failure to maintain either a clean driving record, a valid driver’s license and an acceptable criminal background check may result in the employee’s reassignment or dismissal. I understand that, if hired, I am an employee-at-will. This means that my employment can be terminated at any time, with or without notice or cause for any reason. Living In Fulfilling Environments (L.I.F.E.), Inc. does not utilize employment contracts in any form.


Image Verification
captcha
Please enter the text from the image:
[Refresh Image] [What's This?]

Our principle objective is to become an asset to all supported individuals and agency personnel by nurturing a corporate culture that focuses on:

  • Professionalism
  • Mutual Respect
  • Enhancement of Human Dignity
  • Continual Personal Growth
  • Skill Enhancement Through Progressive Training
  • Complete and Open Communication
  • Relationship Building
  • Participatory Management
  • System Assessment and Development
  • Personal Role-Modeling
  • Client-Centered Supports
  • Exceptional Client Services

Our desire is to improve the quality of life for the individuals we support by providing comprehensive assistance to all personnel employed by L.I.F.E. Inc.