Life Management Consultants 3708 Fourth Avenue Beaver Falls, PA 15010 (724)843-3677
PERSONNEL APPLICATION FORM
Name:
(Last, First, Middle)
Telephone#
Address:
U.S. Citizen:
If “No”, do you have a valid work permit? Yes No
Are you a resident of Pennsylvania? Yes No If yes, How long? years
Are you at least 18 years of age? Yes No
U.S. Veteran? Yes No
Do you have a valid driver’s license? Yes No Lic# State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Do you have reliable transportation? Yes No
Is anyone currently employed by our agency a relative? Yes No
List name and relationship below:
EDUCATION
Name and Address of Educational Institution, Dates Attended, Credits Diploma/Degree Major :
College/University:
Degree and Major:
Professional/Graduate:
Other Schooling (Specify):
EMPLOYMENT HISTORY
Please list names of employers in order with present or last employer listed first.
Rate of Pay: (Hourly Rate)
May We Contact Employer? Yes No
Dates of employment (month/yr.):
Employer Name:
PAST HISTORY:
“Previous convictions are not necessarily a bar to employment. All information will be considered on a case by case basis.”
Have you ever been convicted of a criminal offense? (Do not include minor traffic citations or offenses committed before age 18.) Yes No
If yes, provide details such as nature of offense (felony, misdemeanor, etc), date, etc.
Are there any criminal charges pending? Yes No
If “yes”, provide details below
REFERENCES
Please provide three personal references (Not Relatives and have known over five years)
Name: Phone #
Can you work Weekends? Yes No
Can you sleep overnight? Yes No
Can you work holidays? Yes No
Are you seeking part-time or full-time employment? Part-time Full-time
How did you hear about our agency?
I certify that the information above is correct to the best of my knowledge and belief. I am aware that any false or misleading statements contained herein will be considered grounds for dismissal. All information above will be verified.
***All Applicants must submit to post-offer urine drug screening as a condition of their continued employment***