LifeSpan’s COVID-19 Operating Procedures Updated

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Employment Application

"*" indicates required fields

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP / Postal Code

Home Phone Number

Cell Phone Number

Email*

Drivers License*

Yes

No

State Issued

Are you over eighteen (18) years of age?*

Yes

No

Do you have the legal right to work in the United States?*

Yes

No

Education

High School*

Location*

City State Country

Graduate*

Yes

No

Degree

College or University

Location

City State Country

Graduate

Yes

No

Degree

Employment Desired

Position Applying For*

Location*

Employment Sought*

Full-time

Part-time

Temporary

Volunteer

Salary Desired*

Date Available*

MM slash DD slash YYYY

Currently Employed*

Yes

No

May we make inquiries from your current employer?*

Yes

No

Past employer?*

Yes

No

Additional Information

Have you ever been convicted of a felony that is substantially related to the position you are applying for?*

Yes

No

Have you ever been employed by this agency?*

Yes

No

If so, when?

Have you ever applied to this this agency for employment?*

Yes

No

If so, when?

Employment/Volunteer Experience

Please list 2, beginning with the most recent.

Employer*

Position*

Date Employed (From - To)*

Hours per Week*

Salary (Starting - Final)*

Supervisor*

Phone Number*

Brief Description of Duties*

Employer*

Position*

Date Employed (From - To)*

Hours per Week*

Salary (Starting - Final)*

Supervisor*

Phone Number*

Brief Description of Duties*

Resume or Cover Letter*

Accepted file types: pdf, rtf, Max. file size: 5 MB.

References

Please list 3 persons (not related to you) that you have known at least one year. Professional references preferred.

Name*

First Last

Title*

Years Known*

Address*

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

Phone Number*

Name*

First Last

Title*

Years Known*

Address*

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

Phone Number*

Name*

First Last

Title*

Years Known*

Address*

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

Phone Number*

Conditions of Application and Employment

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT FALSIFICATION OF THIS INFORMATION IS GROUNDS FOR DISMISSAL IN ACCORDANCE WITH LIFESPAN INC. POLICY. I AUTHORIZE THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING INFORMATION TO LIFESPAN INC. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF LIFESPAN INC. AND MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE BY LIFESPAN INC. AND/OR MYSELF.

Yes

No

Signature*

Date*

MM slash DD slash YYYY

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Get In Touch

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Email

Name

This field is for validation purposes and should be left unchanged.

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Hours

The Administrative/ Care Management Office is open Monday through Friday from 8:30 am to 4:30 pm.

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LifeSpan, Inc • 314 E. 8th Ave. Homestead, PA 15120 • Phone: 412.464.1300 • Fax: 412.461.7118