Life Management Consultants
3708 Fourth Avenue
Beaver Falls, PA 15010
(724)843-3677

PERSONNEL APPLICATION FORM

Name:

____________________________________________________________________
(Last, First, M.I.) (Maiden Name)

Social Security # _____-____-________

Telephone# (Home)_______-_______-________ (Work)_______-_______-________

Address:

______________________________________________________________________
City/County , State , Zip Code

U.S. Citizen: Yes No

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 Issued_____________________

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 :

__________________________________________________________________________________________

High School : _________________________________________________________________________________

College/University : _____________________________________________________________________________

Professional/Graduate : __________________________________________________________________________

Other Schooling (Specify) : _______________________________________________________________________

EMPLOYMENT HISTORY

Please list names of employers in order with present or last employer listed first.

Employer Name:________________________________________ Rate of Pay: __________(Hourly Rate)

Address:_______________________________________________ Number Hours worked per week_______

Telephone # ___________________________ Immediate Supervisor________________________________

Duties/Responsibilities_____________________________________________________________________

Reason For Leaving_______________________________________________________________________

May We Contact Employer? Yes No

Dates of employment (month/yr.): From__________ To:____________

Employer Name:________________________________________ Rate of Pay: __________(Hourly Rate)

Address:_______________________________________________ Number Hours worked per week_______

Telephone # ___________________________ Immediate Supervisor________________________________

Duties/Responsibilities_____________________________________________________________________

Reason For Leaving______________________________________________________________________

May We Contact Employer? Yes No

Dates of employment (month/yr.): From__________ To:____________

Employer Name:________________________________________ Rate of Pay: __________(Hourly Rate)

Address:_______________________________________________ Number Hours worked per week_______

Telephone # ___________________________ Immediate Supervisor________________________________

Duties/Responsibilities_____________________________________________________________________

Reason For Leaving_______________________________________________________________________

May We Contact Employer? Yes No

Dates of employment (month/yr.): From__________ To:____________

Employer Name:________________________________________ Rate of Pay: __________(Hourly Rate)

Address:_______________________________________________ Number Hours worked per week______

Telephone # ___________________________ Immediate Supervisor________________________________

Duties/Responsibilities_____________________________________________________________________

Reason For Leaving_______________________________________________________________________

May We Contact Employer? Yes No

Dates of employment(month/yr.): From__________ To:____________

“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 : _______-_______-________
Address:____________________________________________________

Name:________________________ Phone : _______-_______-________
Address:____________________________________________________

Name:________________________ Phone : _______-_______-________
Address:____________________________________________________

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?

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***

Signature_______________________________________________ Date_________________________