Application for Employment

APPLICATION FOR EMPLOYMENT

Applications are considered for all positions, and employees are treated during employment, without regard to, for example, race, color, religion, sex, national origin, age, or disability.

Last Name *

First Name *

Middle Name *

Street Address

City

State/Province

ZIP / Postal Code

Phone

Social Security Number

If employed, and you are under 18, can you furnish a work permit?

Have you filed an application here before?

If yes, give date

Have you ever been employed here before?

If yes, give date

Are you employed now?

May we contact your present employer?

Are you prevented from lawfully becoming employed in this country?

If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired.

On what date would you be available for work?

Are you available to work *Full-timePart-timeTemporary

Please Indicated Days and Hours You Are Available For Work (Be Specific)

Sunday (From - To) AM

Sunday (From - To) PM

Monday (From - To) AM

Monday (From - To) PM

Tuesday (From - To) AM

Wednesday (From - To) AM

Tuesday (From - To) PM

Wednesday (From - To) PM

Thursday (From - To) AM

Thursday(From - To) PM

Friday(From - To) PM

Friday (From - To) AM

Saturday (From - To) AM

Saturday(From - To) PM

Are you on a lay-off and subject to recall?

Have you ever been convicted of a crime?YesNo(Conviction of a criminal offense will not necessarily preclude your employment.)

Have you been convicted of a felony within the last 7 years?YesNo(Conviction of a criminal offense will not necessarily preclude your employment.)

If yes, please explain

Veteran of the U.S. Military Service?YesNo

If yes, please explain

List professional, trade, business or civic activities and offices held. (You may exclude those which indicate race, color, religion, sex or national origin):

Education

ELEMENTARY

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Name

Location

Length of Course:

Was Course Completed:

Subject:

General:

HIGH SCHOOL

School Name

Years Completed: (Circle)9101112

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Name

Location

Length of Course:

Was Course Completed:

Subject:

General:

UNIVERSITY

School Name

Years Completed: (Circle)1234

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Name

Location

Length of Course:

Was Course Completed:

Subject:

General:

GRADUATE

School Name

Years Completed: (Circle)1234

Diploma/Degree

Describe Course of Study

Describe Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities

Name

Location

Length of Course:

Was Course Completed:

Subject:

General:

Honors

Application for Employment

Lutheran Living Communities-Davenport Campus

Contact information:

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