Life Services Alternatives
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LSA Employment Application
Last Name, First Name, Middle
Mailing Address (if different than present address)
Position applying for:
Are you applying for:
Per Diem work?
What days and hours are you available for work?
Are you available to work on weekends?
Would you be able to work overtime, if necessary?
If hired, what date can you start work?
How did you hear about this job opening? (If referred by an employee, please name them here)
Have you ever applied to or worked for Life Services Alternatives before?
If yes, when?
If hired, would you have a reliable means of transportation to and from work?
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of legal minimum age.)
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
If no, describe the functions that cannot be performed.
Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.
We may refuse to hire relatives of present employees if doing so could results in actual or potential problems in supervision, security, safety, or morale, or if doing so could create conflicts of interest.
Education, Training, & Experience
Please provide the name, city and state, degree or diploma earned, and if you graduated from each of the below categories.
Please provide licensing/certification information (if applicable):
Name of license/certification:
Has your license/certification ever been revoked or suspended?
If yes, state reason(s), date of revocation or suspension, and date of reinstatement.
Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at Life Services Alternatives?
If yes, please explain:
List below three persons not related to you who have knowledge of your work performance within the last three years. Please list their name, email, phone number, company/job title, and number of years acquainted.
List below all present and past employment starting with your most recent employer (last seven years). You must complete this section even if attaching a resume. Please include name of employer, phone number, supervisor's name, full address, dates of employment, position and duties, reason for leaving, and if they're your current employer/if we can contact them for a reference?
Please read carefully, initial under each paragraph and sign below
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I agree that the company shall not be liable, in any respect, if my employment is terminated because of misstatements or pertinent omissions made by me in this application
I authorize Life Services Alternatives to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company's designated representative.
I agree, as a condition of my employment (should I be employed by the Company), to submit to a medical examination if requested and based on the position that I accept, I further agree to the search or examination of myself or personal property while on the company's premises or while conducting its business elsewhere. I also authorize any company, school, police or security personnel, or other person to give any information regarding my employment, habits, ability, or any other characteristics whatsoever, together with any information they have regarding me whether or not it is in their records. I hereby release all physicians, examiners, companies, schools, or other persons from liability for any damages whatsoever for such testing, examining, or issuing this information. It is agreed and understood that completion of this application does not mean a job opening exists and in no way obligates the company to employ me. I understand that all offers of employment are contingent upon passing the company's prescribed physical examination and drug screening.
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.
In the event of employment, I will comply with all company rules and regulations as established from time to time including the company's substance abuse policy. I am willing to work all assigned overtime or other special work assignments as requested by the company. Furthermore, since the company does not offer contracts of employment (unless signed in writing by Executive Director and Human Resources Director), I understand that nothing contained herein is intended to create a contract between the company and me for either employment or the provision of any compensation or benefits.
I hereby understand and acknowledge that any employment relationship with this Company is of an “At-Will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time, with or without notice, and with or without cause. It is further understood that this “At-Will” employment relationship may not be changed by any written document or by verbal agreement unless such change is specifically acknowledged in writing by Executive Director and Human Resources Director. I also understand that Life Services Alternatives, Inc. retains the right to amend, modify, add, or delete any or all policies or procedures at its sole and absolute discretion with or without prior notice.
During my employment with Life Services Alternatives, Inc. and after my employment ends, I agree not to disclose any confidential or proprietary information regarding operating and trade secrets including LSA process and procedure binders. I will not use or disclose any confidential information of any current or former resident, employee or other person to whom I have an obligation of confidentiality. Rather, will be expected to use only that information which generally know and used by persons with training and experience comparable to common knowledge in the industry or otherwise legally in the public domain, or which is otherwise provided or developed by the Company. I further agree that with respect to any civil litigation involving Life Services Alternatives, Inc. in which I am a potential witness and which does not involve an actual or potential claim by me personally, I will not discuss the facts of the case with any third parties without first notifying Life Services Alternatives, Inc. or unless a representative or attorney of Life Services Alternatives, Inc. is present. A copy of this form may be used as the original. The use of results from this form and/or tests will be used for prudent employment decisions.
The Company will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws.
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