SECTION 1: General Information
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Telephone:
Email:
Soc. Security Number:
SECTION 2: LRS Intersest
Position Applying For:
Type of Employment Desired:
When are you available to start?
Referral Source:
Are you currently employed?
If so, may we contact your current employer?
Have you filed out an application with LRS before?
If yes, please give the dates:
Have you ever been employed by LRS before?
Are you 18 years of age or older?
Ae you legally eligible for employment in this Country?
(Proof of U.S. citizenship or immigration status will be required upon employment.)
SECTION 3: Occupational Requirement
NOTe: Please answer the next set of questions below accordingly. The checkmark indicates that the information requested is a bona-fide occupational requirement; a safety or security requirement; or otherwise legally permissible. If the box is not checked, you need not answer the sub-questions.
Bonding
When?
For What Position?
Driver's License
Which State?
Expiration Date:
Restrictions (if applicable):
Military Service
Branch Served:
Active duty from:
Discharge Date:
Discharge Rank/Grade:
Nature of Duties:
SECTION 4: Previous Employment
NOTE: Start with your present or most recent employer. Please include both paid and volunteer positions.
Most Recent Employer:
Employer's Telephone:
Employer's Address:
Name of Supervisor:
Dates Employed: From
Job Title:
Hourly Rate or Salary: Starting
Reason for Leaving:
Employer:
Employer's Telephone:
Employer's Address:
Name of Supervisor:
Dates Employed: From
Job Title:
Hourly Rate or Salary: Starting
Reason for Leaving:
Employer:
Employer's Telephone:
Employer's Address:
Name of Supervisor:
Dates Employed: From
Job Title:
Hourly Rate or Salary: Starting
Reason for Leaving:
Please list additional employer's here:
Employer:
Employer's Address:
Employer's Telephone:
Dates Employed: From
Employer:
Employer's Address:
Employer's Telephone:
Dates Employed: From
Employer:
Employer's Address:
Employer's Telephone:
Dates Employed: From
SECTION 5: Educational Record
Grammar School:
Number of Years Attended:
City:
High School:
Number of Years Attended:
City:
Did you Graduate?
Type of Degree or Diploma:
College:
Number of Years Attended:
City:
Did you Graduate?
Type of Degree or Diploma:
Other Formal Education:
List professional, trade, business, or civic activities and offices held. Do not include those activities that would tell us your race, sex, religion, national origin or protected status.
Organization:
Offices Held:
Organization:
Offices Held:
Organization:
Offices Held:
List other special skills, awards or qualifications acquired from employment or other experiences that you would like to be considered:
SECTION 6: References
NOTE: Do not include past employers or relatives.
Name1:
Occupation:
Years Known:
Telephone:
Name2:
Occupation:
Years Known:
Telephone:
Name3:
Occupation:
Years Known:
Telephone:
Name4:
Occupation:
Years Known:
Telephone:
SECTION 7: Certification and Agreement
I certify that all information contained in this application is true and correct. I understand and agree that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cuase and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.
I give the employer the right to investigate all references and to secure additional information about me if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.
The employer is an equal opportunity employer. No question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state or federal law.
