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THE SOLUTION FOR FAMILIES

SERVICES FOR ADULTS AND CHILDREN

Hire Packet Checklist

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

YYYY

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address (if different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Message Phone Number:

(###)

###

####

Email *

What hours and days can you work? *

EMPLOYMENT DESIRED

Position: *

Date you can start:

YYYY

Rate of pay desired:

Have you ever been employed by LSF before?

Yes

If 'Yes', When? and Where?

Are you employed now?

Yes

If so, may we inquire of your present employer?

Yes

If you are hired, can you provide proof that you are authorized to work in the United States?

Yes

Have you ever been convicted of a crime other than a minor traffic offense?

A conviction in itself does not bar employment. Factores such as the nature and gravity of the crime, the length of time that has passed since the conviction and/or completion of any sentence, and the nature of the job for which you have applied will be considered.

Yes

If 'Yes', please list each conviction:

EDUCATION

High School, Name and Location

Number of Years Completed:

Did you graduate?

Yes

College, Name and Location

Number of Years Completed:

Did you Graduate?

Yes

Subjects, Degrees, Certificates and/or Licenses Received:

Graduate School, Name and Location

Number of Years Completed:

Did you Graduate?

Yes

Subjects, Degrees, Certificates and/or Licenses Received:

Trade, Business or Correspondence School, Name and Location

Number of Years Completed:

Did you Graduate?

Yes

Subjects, Degrees, Certificates and/or Licenses Received:

Subjects of special study or research work:

Please list any other skills or specific software you have experience using that are job related:

EMPLOYMENT

List below your previous employers, starting with the most recent one first. Include and explain any periods of unemployment that lasted more than one month.

Company:

Supervisor's Name and Title:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Employed From:

YYYY

Employed To:

YYYY

Final Rate of Pay:

Position Held:

Reason for Leaving:

Company:

Supervisor's Name and Title:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Employed From:

YYYY

Employed To:

YYYY

Final Rate of Pay:

Position Held:

Reason for Leaving:

Company:

Supervisor's Name and Title:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Employed From:

YYYY

Employed To:

YYYY

Final Rate of Pay:

Position Held:

Reason for Leaving:

Company:

Supervisor's Name and Title:

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Employed From:

YYYY

Employed To:

YYYY

Final Rate of Pay:

Position Held:

Reason for Leaving:

Are you able to perform essential functions of this job as described in the advertisement, announcement, job posting or interview process with reasonable or no accommodation?

Yes

ADDITIONAL INFORMATION

Please use the space below to list any additional employers, periods of time not worked, or any other information that you believe we should know in considering your application for employment.

Please read carefully then initial each of the following statements:

If I am employed by LSF, I will comply with all work-related requirements set forth by LSF.

I understand that unless expressly informed otherwise, if hired I will be an "at will" employee and agree that the employment relationship can be terminated at any time, for any or no reason, with or without notice, by me or by LSF.

Initial here:

I understand that no manager or representative of LSF, except the CEO, will ever have any authority to create other than at-will employment or to enter into any employment contract and that all such contracts must be in writing and signed by the CEO and myself. I also understand that unless otherwise stated in an employment contract, LSF reserves the discretion to change, withdraw or interpret policies, including wages, hours, shifts or working conditions.

Initial here:

I agree that, if requested, I must pass a pre-employment physical exam and/or pre-employment drug scree and I understand that LSF reserves the right to test employees for drugs and/or alcohol if reasonable suspicion of use exists.

Initials here:

I authorize LSF to run a criminal or other background check. I understand that a criminal record will not necessarily disqualify me from employment.

Initials here:

I authorize LSF to conduct a thorough investigation of all statements contained herein or information provided during the application process, including all references listed, my employmet record, education, and all other matters relating to my suitability for employment and any pertinent information they may have, personal or otherwise, and release from all liability or responsibility LSF, its agents, and all persons, companies or corporations providing information to LSF about me.

Initials here:

I certify that all answers to questions in this application and all additional information I may have submitted are true and complete to the best of my knowledge. I understand that giving false information, misrepresenting facts, and material omissions may be grounds for denial of employment or discharge, if hired.

Initials here:

Applicant's Signature

Type First Name and Last Name.

Date

YYYY

We are an equal opportunity employer, dedicated to a policy of nondiscrimination in employment on the basis of race, color, national origin, religion, age, gender, or any status protected under applicable local, state or federal nondiscrimination laws. It is our intention that all participants be given equal opportunity and that selection decisions are based on job-related factors. No applicant will be rejected as a result of a disability that, with reasonable accommodation, does not prevent performance of the essential job duties.

Any person needing reasonable accommodations in the application process should contact the Human Resources Department

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