Life'sWork Application for Employment

Life’sWork of Western PA is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.

Today's Date(Required)

Position applying for(Required)

Employment Type(Required)

Full Time

Part Time

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Available for Work(Required)

Desired Salary

Are you eligible for employment in the US?(Required)

Yes

Are you over 18 years old?(Required)

Yes

How did you hear of us:(Required)

Referral Name(Required)

Upload Resume(Required)

Max. file size: 128 MB.

Upload Cover Letter(Required)

Max. file size: 128 MB.

Education

(If offered employment, you will be required to provide documentation to verify eligibility.)
EDUCATION: Please indicate education or training which you believe qualifies you for the position you are seeking.

High School: No. of Years Completed(Required)

Diploma?(Required)

G.E.D. School(Required)

G.E.D. School Address(Required)

City State

College and/or Vocational School No. of Years Completed

College and/or Vocational School(Required)

College and/or Vocational. School Address(Required)

City State

Major

Degree or Certificate Earned

Other Training or Degrees

Other Training or Degrees Address

City state

Course

Address

City state

Type of License Held

License Number

License Expiration Date

Other Professional Memberships

(You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status.)

Skills

Data entry

Excel

MS Word

Access

Typewriter (WPM)

Other Software Skills

Employed by Life'sWork or The NorthShore Community Alliance

Yes

Dates of Employment

Previous Position

Most Recent Employment

Can we contact your previous employer(s)(Required)

Yes

Employed Under Different Name; If so, List Name. If not, please put N/A(Required)

Most Recent Employer(Required)

Most Recent Employer Address(Required)

Street Address City State

Most Recent Employer Phone(Required)

Most Recent Position(Required)

Dates of Most Recent Employment From(Required)

Mo/Yr

Dates of Most Recent Employment To(Required)

Mo/Yr

Most Recent Salary(Required)

Most Recent Supervisor(Required)

Most Recent Employment Department(Required)

Most Recent No. of Hours/Week(Required)

Most Recent Employment Type(Required)

Full Time

Part time

Most Recent Employment Duties:(Required)

Reason for Leaving Most Recent Place of Employment(Required)

Previous Employment

Previous Employer (2)

Employer (2) Address

Street Address City State

Employer (2) Phone

Employer (2) Position

Employer (2) No. of hours

Employer (2) Type

Full time

Part Time

Employer (2) Supervisor

Employer (2) Department

Dates of Previous Employer (2) – From

Mo/Yr

Dates of Previous Employer (2) – To

Mo/Yr

Previous Employer (2) Salary

Previous Employment (2) Duties:

Reason for leaving

Previous Employer (3)

Employer (3) Address

Street Address City State

Employer (3) Phone

Employer (3) Position

Employer (3) No. of hours

Employer (3) Type

Full time

Part Time

Employer (3) Supervisor

Employer (3) Department

Dates of Previous Employer (3) – From

Mo/Yr

Dates of Previous Employer (3) – To

Mo/Yr

Previous Employer (3) Salary

Previous Employment (3) Duties:

Reason for leaving

Previous Employer (4)

Employer (4) Address

Street Address City State

Employer (4) Phone

Employer (4) Position

Employer (4) No. of hours

Employer (4) Type

Full time

Part Time

Employer (4) Supervisor

Employer (4) Department

Dates of Previous Employer (4) – From

Mo/Yr

Dates of Previous Employer (4) – To

Mo/Yr

Previous Employer (4) Salary

Previous Employment (4) Duties:

Reason for leaving

Explain Any Gaps in Work History:

Have you ever been discharged or asked to resign from a job?(Required)

Yes

If Yes, please explain.

Professional References

Please list three professional references. These individuals cannot be friends or relatives of yours. We will contact these individuals as needed during our hiring process.

Reference 1 – Name(Required)

First Last

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Title(Required)

Years Known(Required)

Relationship to Reference(Required)

Reference 2 – Name(Required)

First Last

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Title(Required)

Years Known(Required)

Relationship to Reference(Required)

Reference 3 – Name(Required)

First Last

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Title(Required)

Years Known(Required)

Relationship to Reference(Required)

Reference 4 – Name(Required)

First Last

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Title(Required)

Years Known(Required)

Relationship to Reference(Required)

APPLICANT’S CERTIFICATION AND AGREEMENT

In making this application for employment an investigative consumer report may be prepared whereby information is obtained through personal interviews with your neighbors, friends, or other acquaintances. Such an inquiry would include information as to character, general reputation, personal characteristics and mode of living.

You have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.

I authorize you to communicate with persons listed as references, former employers, and any others with whom you desire to check. I agree to hold such persons harmless with respect to any information they may give about me.

If employed, I agree to engage in no outside activity which would involve a material conflict of interest with, or which could reflect adversely on Life’sWork of Western PA. I understand this decision is to rest with the company.

In consideration of my employment, if I am employed, I agree to conform to the employment policies of Life’sWork of Western PA, and I understand that my employment is “at will” and can be terminated, with or without notice, at any time, at the option of either the Company or myself. I understand that no representative of the Company, other than the President, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

I understand that completion of this Application For Employment does not guarantee that I have been employed by Life’sWork of Western PA.

I hereby affirm that my answers to these statements and questions are true and correct to the best of my knowledge. I have not knowingly withheld any fact or circumstance that would, if disclosed, affect my application unfavorably.

I understand that any misrepresentation, deception, or false statement made in this Employment Application may result in my not being considered for employment, and if not discovered by Life’sWork of Western PA until after my becoming employed, is grounds for, and may result in, my immediate termination.

I understand that Life’sWork of Western PA requires the successful completion of a urinalysis for drug testing purposes and/or a blood alcohol test as a condition of employment.

By submitting this Application for Employment, I hereby consent to either or both of said tests, at the Company’s discretion.

Signature(Required)

Date(Required)

AUTHORIZATION FOR PRIOR EMPLOYER TO RELEASE INFORMATION

(Please read the following statements, sign below, and return to the Human Resources office.) I,

Applicant's Name(Required)

hereby authorize my prior employer,

Prior Employer 1(Required)

to release any and all information relating to my employment with them to Life’sWork of Western PA. I further release and hold harmless both

Prior Employer's (1) Name(Required)

and Life’sWork of Western PA from any and all liability that may potentially result from the release and/or use of such information. I understand that any information released by my prior employer will be held in strictest confidence, that it will be viewed only by those involved in the hiring decision, and that neither I nor anyone else not so involved will not have the right to see the information.

Signature(Required)

Date(Required)

Print Name(Required)

Full Name

(Please read the following statements, sign below, and return to the Human Resources office.) I,

Applicant's Name(Required)

hereby authorize my prior employer,

Prior Employer 2(Required)

to release any and all information relating to my employment with them to Life’sWork of Western PA. I further release and hold harmless both

Prior Employer's (2) Name(Required)

Signature(Required)

Date(Required)

Print Name(Required)

Full Name

(Please read the following statements, sign below, and return to the Human Resources office.) I,

Applicant's Name(Required)

hereby authorize my prior employer,

Prior Employer 3(Required)

to release any and all information relating to my employment with them to Life’sWork of Western PA. I further release and hold harmless both

Prior Employer's (3) Name(Required)

Signature(Required)

Date(Required)

Print Name(Required)

Full Name

(Please read the following statements, sign below, and return to the Human Resources office.) I,

Applicant's Name(Required)

hereby authorize my prior employer,

Prior Employer 4(Required)

to release any and all information relating to my employment with them to Life’sWork of Western PA. I further release and hold harmless both

Prior Employer's (4) Name(Required)

Signature(Required)

Date(Required)

Print Name(Required)

Full Name

Comments

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