Job Application - Lehigh Human Support Services | Lehigh Human Support Services

Name *

First

Middle

Last

Date of Birth: *

Ex: 5/1/1985

Drivers License #

Ex: 123456789

Do you have a Driver's License? *

Yes
No

Do you have a working car?

Yes
No

Enter Your Street Address *

City, State, Zip Code: *

Telephone # *

Ex: 484-111-0000

Email *

Are You a Veteran?

Yes
No

Have you ever been convicted of a crime? *

Yes
No

If “Yes” above state conviction and year. If “No” above then skip

If hired are you willing to submit to a background check that includes your SSN *

What Position you are applying for:

Available date to start:

Desired pay:

I am applying for:

Most Recent Employer 1. Employer's Name:

Employer 1 Address, City, Zip, State:

Job Title 1:

Date Employment 1. Enter Start - End Date:

Ex: May 25th 2010-Present

Starting & Ending Pay Rate for Job 1:

Ex: $8/hr - $12/hr Or $30K a year

Most Recent Employer 2. Employer's Name:

Employer 2 Address, City, Zip, State:

Job Title 2:

Date Employment 2. Enter Start - End Date:

Starting & Ending Pay Rate for Job 2:

The highest degree I have earned:

What year did you graduate:

Name of School or College:

Street Address of School or College, City, State, Zip Code:

Do you have a special license or certification:

Yes
No

Are you certified on CPR?

Yes
No

If you have, List Name of Certification & Year of Certification:

Name of Institution granting the Certification:

Street Address of Institution or College, City, State, Zip:

References: List Reference 1. Full Name:

List Address, City, State, Zip for Reference 1:

List Email for Reference 1:

List Telephone Number for Reference 1:

Reference 2. Full Name:

List Address, City, State, Zip for Reference 2:

List Email for Reference 2:

List Telephone Number for Reference 2:

Race:

Type Today's Date: *

Ex: 1/20/2017 Or January 20th 2017

I certify that my answer are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my employment being terminated *

Confirmed

Type your Initials:

Please Sign Here & Date (You will Sign During Interview):

*To be considered for employment, applicants will be responsible for the cost of their background check, if a recent background check is available from a previous employer (within 6 months) it could be accepted.

I accept

Job Application - Lehigh Human Support Services

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