LIFE Incorporated | Online Application Form

Personal Information

Applicant Name *

Date

Present Address

City

State

Zip Code

Telephone

Cell

Social Security Number

Emergency Contact (Name & Number)

Relationship to Applicant

Background

Are you 17 years of age or older?

Yes No

Are you 18 years of age or older?

Yes No

Are you a US citizen?

Yes No

Your job description includes driving. Do you have a valid driver's license?

Yes No

License Number

Expiration Date

State

Auto Insurance?

Yes No

Have you ever been arrested as an adult or juvenile? (include all charges regardless of outcome)

Yes No

If yes, please explain:

Have you ever been convicted of a crime?

Yes No

If yes, type of crime

How long ago

Do you have a communicable disease?

Yes No

If yes, please explain:

It is the policy of LIFE Incorporated to drug test all new hires. Do you consent to a saliva sample drug test?

Yes No

Education

Highest Completed Year of High School

Diploma / GED

HS Diploma GED Neither

Highest College Year

College / University Name(s)

Degree(s) Earned

Other Educational Experiences

Training & Certifications

CPR Certified?

Yes No

CPR Expiration Date

First Aid Certified?

Yes No

First Aid Expiration Date

Assistance with Medications (AWM) Certified?

Yes No

Pre-Employment Questions

Do you have previous experience working with individuals with developmental disabilities (paid or volunteer)? If yes, please explain.

What are your expectations of LIFE Incorporated as an employer?

Why do you think you would work well with the Developmentally Delayed population?

What would a past employer say are two of your strengths?

Position & Availability

Position(s) Applying For

Residential Habilitation Technician RH Trainer Developmental Therapy Technician DDA Trainer Developmental Specialist / IBI Professional Program Coordinator Other

Hours Available to Work

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preference

Full-Time Part-Time

Willing to start Part-Time if preferred full-time?

Yes No

Employer Name

Phone

Supervisor

Your Position

From

To

Reason for Leaving

May we contact your current or previous employers?

Yes No

If no, please explain:

Authorization & Signature

I grant permission for the employers listed above to release information to LIFE Incorporated and release them from liability resulting from such release. I understand the employer, if directed by the courts, may release other information. Any misleading or inaccurate statements on this application may result in immediate termination of employment.

Signature (type your full name)

Date