PERSONAL DATA

To express an interest in a position with our Center please complete this application. Applications are required on all persons who are placed by the Center. Failure to provide sufficient, truthful (and verifiable) information is grounds for the application to be rejected and not considered for a placement opportunity.

*Required fields

What position or positions are you applying for?
*Last Name
*First Name
*Middle Name
*Address: *City:
*Zip Code: *Telephone:
*Email: *Are you at least 18 years of age? Yes No
*Are you legally authorized to work in the United States?Yes No
*How did you hear about LifePath Systems?
*List all other names used in school or employment.
*Are you seeking:
Employment Volunteer Opportunity Internship Practicum
*How many hours per week do you want to work?
*Do you currently use any illegal substances? Yes No
*Have you ever been convicted of a crime? Yes No
If yes, explain in detail:
A conviction may not disqualify you, but a false statement will. LifePath Systems may require additional information related to conviction of misdemeanors and deferred adjudication.
EMPLOYMENT HISTORY
*Employer: *Start Date: *End Date
*Position Title: *Start Pay: *End Pay:
*Job Duties:
*Reason for Leaving:
*Supervisor Name: *Telephone:
*May we contact for Reference? Yes No

Employer: Start Date: End Date
Position Title: Start Pay: End Pay:
Job Duties:
Reason for Leaving:
Supervisor Name: Telephone:
May we contact for Reference? Yes No

Employer: Start Date: End Date
Position Title: Start Pay: End Pay:
Job Duties:
Reason for Leaving:
Supervisor Name: Telephone:
May we contact for Reference? Yes No
EDUCATION All applicants will be required to provide proof of education via diploma, degree, transcript, license, and/or certifications.
HIGH SCHOOL

*Name of High School:

*Location of High School:
(city and state)
*Did you graduate or receive your GED? Yes No
*Highest grade completed?
COLLEGE
School: Major: GPA:
School: Major: GPA:
School: Major: GPA:
College degree received: Yes No
Degree/Degrees:
Credentials: Check all that apply (transcripts/records must be submitted to verify credentials).
HS Diploma/GED
LCDC
LBSW
Speech Therapist
AA/AS
LPC-1
LMSW
Physical Therapist
BA/BS/BSW
LPC/LPC-S
LCSW
Occupational Therapist
MA/MS/MSW
PhD, PsyD
LMFT
LVN or RN
*Have you ever lost your state license or received disciplinary actions? Yes No
If yes, explain in detail:
Have you ever lost or had limitations placed on your hospital privileges (MDs)? Yes No
If yes, explain in detail:
*Describe any adverse actions that may present a risk management concern (malpractice actions, insurance cancellations, criminal convictions, Medicare/Medicaid sanctions, ethical violations, etc.)
EMPLOYMENT REFERENCES

Applicants must list 3 professional and/or educational references.

*Ref Name: *Company Name:
*Email: *Telephone:

*Ref Name: *Company Name:
*Email: *Telephone:

*Ref Name: *Company Name:
*Email: *Telephone:
APPLICANT'S STATEMENT

I certify that the answers given herein are true, correct and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not, and is not intended to be a contract of employment.

I understand and agree that if I become employed with LifePath Systems, I will be required to abide by all rules and regulations of LifePath Systems; and that any false or misleading information given in my application or interview(s) may result in my discharge from that employment.

I understand and agree if selected for employment, my term of employment is not for any definite period. I understand that employment with LifePath Systems is at will, which means that either I or LifePath Systems can terminate the employment relationship at any time, with or without prior notice, and with or without cause.

I also understand that LifePath Systems will check conviction records on applicants recommended for hire may make me ineligible for continued employment and lead to my immediate dismissal.

I understand that I may be requested to sign a release authorizing previous employers to release information concerning my previous employment including, but not limited to, reasons for separation and any information concerning client abuse/client neglect investigations.

*Name: *Date:

DPS Computerized Criminal History (CCH) Verification
I,*, have been notified that a Computerized Criminal History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply.

Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization conducting the criminal history check for background screening is not allowed to discuss any criminal history record information obtained using the name and DOB method. Therefore, the agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I have been made aware that in order to complete this process I must make an appointment with L1 Enrollment Services, submit a full and complete set of my fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company, L1 Enrollment Services. (This fee may be waived by LifePath Systems.)

Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.

By checking this box, I confirm I understand that a fingerprint record search will be performed. (required)

APPLICANT EEO DATA FORM The information requested is required for conducting criminal history background checks, as well as for Equal Employment Opportunity purposes. This form will be separated from the application, and this information will not be considered for employment decisions.
*Name: *Social Security #:
*Driver's License Number: *Expiration Date:
*State: *Date of Birth:
*Gender: Male Female
*Ethnicity:
American Indian or Alaska Native
Asian (Not Hispanic or Latino)
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White (Not Hispanic or Latino)
Two or More Races
I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for employment, but will be used solely for the purpose of obtaining criminal history record information.
*Name:
*Date:
By checking this box, I confirm I understand a criminal history record will be performed. (required)
UPLOAD RESUME

Please click to upload resume