Street Address. Home Telephone. City, State, Zip. Business or Cell Telephone. Have you applied for employment with us pr
Lifestyles for the Disabled, Inc. 930 Willowbrook Road, Bldg 12-G, Staten Island, NY 10314 Phone: 718-983-5351 ● Fax: 718-983-5383 ● www.lfdsi.org
APPLICATION FOR EMPLOYMENT PROSPECTIVE EMPLOYEES WILL RECEIVE CONSIDERATION WITHOUT DISCRIMINATION BASED ON RACE, CREED, COLOR, SEX, AGE, NATIONAL ORIGIN, CITIZENSHIP STATUS OR ANY CONDITION PRESCRIBED BY STATE OR LOCAL LAW.
PERSONAL INFORMATION: (COMPLETE ALL APPLICABLE INFORMATION) Last Name
First
Middle
Date of Application
Street Address
Home Telephone
City, State, Zip
Business or Cell Telephone
Have you applied for employment with us previously?
Social Security Number
Position(s) Applied For:
Expected Pay
Do you have any relatives or friends that are currently or previously employed by Lifestyles? If “Yes,” list their name. __No __Yes Name:_______________________________________________
Work Availability:
Have you ever been convicted of any crimes in the past ten years, excluding misdemeanors and summary offenses, which have not been annulled? __Yes __No If “Yes” describe in full.
When could you start employment?
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Other special training or skills (languages, machine operation, etc.)
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__Full Time __Part Time __Temporary
Have you ever been bonded? __Yes __No If “Yes,” with what employers?
EMPLOYMENT HISTORY: Present or Last Position
Telephone
Name of Company
Employed (Month & Year) From:_____________
Address (Street, City, State, Zip) 1
Reason for Leaving
________________________________________________________________ Job Description
Starting Salary:_________________________
Name & Title of Supervisor
Ending Salary:__________________________ Supervisor's Telephone
Present or Last Position
Telephone
Name of Company
Employed (Month & Year) From:_____________
Address (Street, City, State, Zip) 2
To:_____________
Reason for Leaving
________________________________________________________________ Job Description
Starting Salary:_________________________
Name & Title of Supervisor
Ending Salary:__________________________ Supervisor's Telephone
Present or Last Position
Telephone
Name of Company
Employed (Month & Year) From:_____________
Address (Street, City, State, Zip) 3
To:_____________
To:_____________
Reason for Leaving
________________________________________________________________ Job Description
Starting Salary:_________________________ Ending Salary:__________________________ Supervisor's Telephone
Name & Title of Supervisor
Lifestyles for the Disabled, Inc. may contact the employers listed above unless you indicate those you do not want us to contact to the right.
Employer(s):______________________________________________________ Reason:__________________________________________________________ Page 2 of 4
Lifestyles for the Disabled, Inc. 930 Willowbrook Road, Bldg 12-G, Staten Island, NY 10314 Phone: 718-983-5351 ● Fax: 718-983-5383 ● www.lfdsi.org
APPLICATION FOR EMPLOYMENT
EDUCATION INFORMATION: High School or GED
Address, City, State
Degree
Business/Trade/Technical
Address, City, State
Degree
Major
College
Address, City, State
Degree
Major
Graduate
Address, City, State
Degree
Major
MILITARY SERVICE: Do you currently serve in the U.S. Armed Forces?
__No
__Yes, in what branch? _______________________________________
Describe any training received relevant to the position for which you are applying. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
PERSONAL REFERENCES: (DO NOT INCLUDE RELATIVES OR FORMER EMPLOYERS) Name
Address, City, State, Zip
1. 2. 3.
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Telephone
Occupation
ADDITIONAL INFORMATION & COMMENTS: MEMBERSHIP IN PROFESSIONAL AND CIVIC ORGANIZATIONS, SPECIAL ACCOMPLISHMENTS, AWARDS, ETC. (EXCLUDE THOSE WHICH MAY DISCLOSE YOUR RACE, COLOR, RELIGION, AGE OR NATIONAL ORIGIN)
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY: •
In consideration of my employment, I agree to conform to the policies and procedures of Lifestyles for the Disabled, Inc. I understand that in accepting this application, Lifestyles is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time.
•
I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any falsified statements on this application or omissions of fact on either this application or during the preemployment process will result in my application being rejected, or, if I am hired, in my employment being terminated.
•
I also understand that any offer of employment is conditional on the completion of pre-employment checks and documentation. I will, upon request, sign all necessary consent forms. I give Lifestyles the right to investigate all references and to secure additional information about me that is pertinent to the position I am seeking. I hereby release Lifestyles and its representatives from liability for seeking this information, and all other persons, corporations or organizations for furnishing such information.
•
I understand that I am required to attend an orientation class, lasting one full day, within 3 months of hire. I agree to adjust my schedule accordingly in order to attend.
This application will be held for 30 days. At the conclusion of that time, unless otherwise notified, I understand that my status as an applicant will end. If I wish to be considered for future employment, I may re-apply by completing a new application. Signature:
Date:
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