Employment Application

AN EQUAL OPPORTUNITY EMPLOYER:

It is our policy to abide by all Federal and State Laws prohibiting employment discrimination solely on the basis of a person's race, color, creed, national origin, age, sex, marital status, or physical handicap, except where reasonable bona fide occupational qualification exists.

Personal & General History

Today's Date: (Required)

Are you 18 years or older? (Required)

First Name (Required)

Middle Name

Last Name (Required)

Maiden Name:

Telephone: (Required)

Email Address: (Required)

Current Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

PREVIOUS ADDRESSES DURING THE LAST FIVE YEARS

Previous Address 1 in the last five years

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Second Previous Address in the last five years

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Other Employment-Related Information

What position(s) are you applying for? (Required)

Select the following options you would consider:

Full-Time
Part-Time
1st Shift
2nd Shift
3rd Shift

Date Available for Employment (Required)

If previously employed by Luther Home of Mercy, please list dates and position held:

Person who referred you:

If you have any relatives that work here, please list:

Police Record

Have you ever been arrested or charged with a misdemeanor or felony?

Education

Did you graduate from high school or do you have a GED?

Name of High School:

List any other education, training, special skills or certifications/licenses that you possess related to this job:

Professional organization membership, honors received, volunteer or community service or other qualifications you have which you feel are related to the position for which you are applying:

EXPERIENCE

Most Recent Employer

Name of Most Recent Employer:

Most Recent Employed Position:

Most Recent Employer Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Most Recent Employment Date Started:

Most Recent Employment Date Ended:

Most Recent Employment Reason for Leaving:

Employer #2

Name of Employer #2:

Employment #2 Position:

Employment #2 Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Employment #2 Date Started:

Employment #2 Date Ended:

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Employment #2 Reason for leaving:

Employer #3:

Name of Employer #3:

Employment #3 Position:

Employment #3 Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Employment #3 Date Started:

Employment #3 Date Ended:

Employment #3 Reason for leaving:

REFERENCES

Reference #1

Reference #1 Name:

Reference #1 Title:

Reference #1 Business:

Reference #1 Phone:

Reference #1 Years known:

Reference #1 - May we contact this person?

Reference #2:

Reference #2 Name:

Reference #2 Title:

Reference #2 Business:

Reference #2 Phone:

Reference #2 Years known:

Reference #2 - May we contact this person?

Reference #3:

Reference #3 Name:

Reference #3 Title:

Reference #3 Business:

Reference #3 Phone:

Reference #3 Years known:

Reference #3 - May we contact this person?

YOU WILL BE SUBJECT TO SCREENING TESTS FOR ILLEGAL DRUGS AND ALCOHOL PRIOR TO HIRING AND DURING EMPLOYMENT

Employment Application

Careers

Personal & General History

Other Employment-Related Information

Police Record

Education

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