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Application for Employment

An Equal Opportunity Employer - We consider all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected Status.

Position(s) Applied For
Date of Application
How Did You Learn About Us?: (where/who?)
 
Last Name    First Name    Middle Name
Address:Number and Street
 City    State    Zip Code
Telephone Number(s)
Cell Number/Alternate
 
1. Are you at least 18 years old?
(If under 18, you will need to provide verification that you are of minimum legal age.)		Yes   No
2. If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?Yes   No
3. If hired, would you have a reliable means of transportation to and from Lifeline office, clients, and vendors?Yes   No
4. Do any of your friends or relatives other than spouse, work here?Yes   No
 If yes, state name, relationship, and location:
5. Have you reviewed and initialed the job description provided with this Application?Yes   No
6. If hired, are you able to perform the essential functions/activities involved in the job or occupation to which you have applied, with or without reasonable accommodation?Yes   No
 If no, describe the functions that cannot be performed:
7. Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?
(Convictions for marijuana-related offenses that are more than two years old need not be listed.)		Yes   No
 If yes, state the nature of the crime(s), when and where convicted, and disposition of the case:
8. DATE AVAILABLE FOR WORK:
   DESIRED SALARY RANGE:		//

FULL TIME  - Please indicate shifts available:
PART TIME  - Please indicate: Mornings   Afternoons   Evenings
TEMPORARY  - Please indicates dates available:
/ to /
ON LAYOFF STATUS & SUBJECT TO RECALL  - Please indicate date laid off:

EDUCATION

SchoolName and Address of SchoolCourse of StudyYears CompletedDiploma/Degree
High School
Undergraduate College
Graduate/Professional
Other (Specify)

WORK EXPERIENCE

Start with your present or last Job. Include any Job-related military service assignments and volunteer activities. You may exclude organizations which Indicate race, color, religion, gender, national origin disabilities or other protected status.

Employer Dates EmployedWork Performed
Address FromTo
Telephone #  
Starting Job Title Hourly Rate/Salary 
Present Job Title StartingFinal 
Supervisor  
Reason for Leaving May we contact? Yes   No
 
Employer Dates EmployedWork Performed
Address FromTo
Telephone #  
Starting Job Title Hourly Rate/Salary 
Present Job Title StartingFinal 
Supervisor  
Reason for Leaving May we contact? Yes   No
 
Employer Dates EmployedWork Performed
Address FromTo
Telephone #  
Starting Job Title Hourly Rate/Salary 
Present Job Title StartingFinal 
Supervisor  
Reason for Leaving May we contact? Yes   No
 
Employer Dates EmployedWork Performed
Address FromTo
Telephone #  
Starting Job Title Hourly Rate/Salary 
Present Job Title StartingFinal 
Supervisor  
Reason for Leaving May we contact? Yes   No

COMMENTS: Include explanations of any gaps in employment and any special comments about employment.

DESCRIBE SPECIALIZED TRAINING, APPRENTICESHIPS, ACTIVITIES THAT WOULD MAKE YOU ESPECIALLY SUITED FOR POSITION:

MILITARY SERVICE: No   Yes

IF YES HAVE YOU OBTAINED ANY SPECIAL SKILLS OR ABILITIES AS A RESULT OF SERVICE IN THE MILITARY:

PERSONAL / PROFESSIONAL REFERENCES Do not include family members or past supervisors.

NamePhone NumberBest Time to CallOccupation

PLEASE WRITE A SHORT PARAGRAPH ABOUT WHY YOU WANT TO WORK WITH OLDER ADULTS AND LIFELINE HEALTHCARE, INC.:

PERSONAL CERTIFICATIONS:

I hereby certify that I have not knowingly withheld any Information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any documented used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize the company to thoroughly investigate my references, work record, education, and other matters related to my suitability for employment. Further, I authorize the references I have listed to disclose to the company any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. in addition, I understand and agree that if I am employed, my employment Is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company's designated representative.

RELEASE AUTHORIZATION

In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance and experience, along with reasons for termination of past employment from previous employers. Further, I understand that information may be requested concerning my workers' compensation claims, motor vehicle operation history and criminal history from various states, private and insurance sources along with other public records available. I understand that the information disclosed may contain information that is protected by Federal and State health and constitutional privacy laws, and I specifically consent to the disclosure of such information. Workers' compensation information will only be requested in compliance with the ADA.

I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY LAW AGENCY, ADMINISTRATOR, STATE AGENCY, INSTITUTION, iNFORMATION SERVICE BUREAU, EMPLOYER OR iNSURANCE COMPANY CONTACTED TO FURNISH THE ABOVE MENTIONED INFORMATION.

I further acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release includes all state and federal agencies including Minnesota's Department of Labor. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be so advised and be given the name of the agency or source of information.

  //

Please type your complete name and today's date above to indicate your signature and authorization.

LIFELINE HEALTHCARE, INC. - An Equal Opportunity Employer

 

 

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