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

Name *

First

Middle

Last

Enter Your Street Address *

City, State, Zip Code: *

Date of Birth: *

Ex: 5/1/1985

Telephone # *

Ex: 484-111-0000

Email *

Do you have a Valid and Current Driver's License? *

Yes
No

Drivers License # *

Ex: 123456789

Do you have a working car?

Yes
No

Are You a Veteran?

Yes
No

Have you ever been convicted of a crime? *

Yes
No

If “Yes” to the above question, please state type of conviction and year. If “No” then skip to the next question.

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

Yes
No

Have you lived in the state of Pennsylvania for less than 2years? (if yes then a FBI Background check will be required) *

Yes
No

What Position you are applying for:

I am applying for: *

Fulltime
Part-Time
Seasonal/Temporary
On-Call

Available date to start:

Days available to work

What shift are you interested in? (Note shift preference can not be guaranteed)

8AM-4PM
4PM-12AM
12AM-8AM

Desired pay:

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:

Highest level of Education *

What year did you graduate:

Name of School or College:

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

Do you have prior work experience in Human Services or as a DSP/DSA *

Yes
No

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

Type your Initials:

THIS COMPANY IS AN AT-WILL EMPLOYER WHERE ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY. IF HIRED, I AGREE TO CONFORM TO THE LAWFUL RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL UNLESS SUCH AGREEMENT IS SIGNED BY THE PRESIDENT OF THE COMPANY. *

Confirmed

Please Sign Here & Date *

Job Application - Lehigh Human Support Services

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