* = Required Information

Application Packet
    
Personal Information
 
Name:*
Last* First* Middle Initial*
   
SS#:* Birth Date:
    
Address:
  Street City State Zip
  
Phone Number: Message(other)Phone#:
  
Emergency Contact: Phone Number:

   
Employment Information
 
Position applied for?: Date Available?:
Same Day Assignments?:   YesNo
Do you have an automobile?: Are you on Bus Line?: Salary Required?:
 
Have you ever been convicted of a felony?:  
If yes, please explain:

   
Education History
 
Last grade completed (circle) High School:  6789101112
Name of High School: Location:
   
Last Year completed (circle) College or Trade School:  1234
Name of College or Trade School: Location:
 
Are there any experiences, special skills, or qualifications, which you feel qualify you to work for LIFEGUIDE HEALTH SERVICES?

References
 
List three (3) personal and/or professional references:
 
Name: Relationship:
Address:
Phone: Years Known:

Name: Relationship:
Address:
Phone: Years Known:

Name: Relationship:
Address:
Phone: Years Known:

Employment History
 
List your last (5) employers starting with the present job. There may be period that you were not employed, please explain:
 
Employer: Address:
Dates employed:   Month:  / Year:    to  Month:  / Year: 
Please, explain any period you were not employed?    /    to    / 
Reason?:
Immediate Supervisor: Company Phone #:
Job Title: Duties / Responsibilities:
Final Wage: Was Separation Voluntary or Involuntary?
Reason?:

Employer: Address:
Dates employed:   Month:  / Year:    to  Month:  / Year: 
Please, explain any period you were not employed?    /    to    / 
Reason?:
Immediate Supervisor: Company Phone #:
Job Title: Duties / Responsibilities:
Final Wage: Was Separation Voluntary or Involuntary?
Reason?:

Employer: Address:
Dates employed:   Month:  / Year:    to  Month:  / Year: 
Please, explain any period you were not employed?    /    to    / 
Reason?:
Immediate Supervisor: Company Phone #:
Job Title: Duties / Responsibilities:
Final Wage: Was Separation Voluntary or Involuntary?
Reason?:

Employer: Address:
Dates employed:   Month:  / Year:    to  Month:  / Year: 
Please, explain any period you were not employed?    /    to    / 
Reason?:
Immediate Supervisor: Company Phone #:
Job Title: Duties / Responsibilities:
Final Wage: Was Separation Voluntary or Involuntary?
Reason?:

Employer: Address:
Dates employed:   Month:  / Year:    to  Month:  / Year: 
Please, explain any period you were not employed?    /    to    / 
Reason?:
Immediate Supervisor: Company Phone #:
Job Title: Duties / Responsibilities:
Final Wage: Was Separation Voluntary or Involuntary?
Reason?:

As an applicant for employment with LIFEGUIDE HEALTH SERVICES, I understand the following:
* I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
* I understand that under conditional offer of employment I am required to submit to pre-employment drug and alcohol screening. The results of such testing may be grounds for withdrawing the offer or employment.
* I must meet the employability requirements of Federal Immigration Law and submit appropriate documentation to satisfy the requirements for completing INS Form I-9.
* If my application for employment is accepted, the effective date of my employment may be time I actually begin to work. If I accept the employment, I agree to comply with and be bound by the safety and health rules and regulations and rules of conduct of LIFEGUIDE HEALTH SERVICES altogether with obligations set forth in the Company policies.
* All information (including information on any accompanying resume) is correct and will be subject to verification.
Information including personal and medical information will not be discussed with anyone other than persons who have proper authorization, information in this application or its information will not be shared, or sold to anyone.
Employer: Reason:
Date:    

* Security Code