LifePath Employment Application

Placement Application

Employment, Volunteer, Student & Contractors

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.

What position or positions are you applying for?
Name:*
Address:*
Email:*
Telephone:*
Are you at least 18 years of age?*
Are you legally authorized to work in the United States?*
How did you hear about LifePath Systems?*
List all other names used in school or employment.*
Are you seeking:*
How many hours per week do you want to work?*
Do you currently use any illegal substances? *
Have you ever been convicted of a crime?*
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*
Job Title:*
Start Pay:*
End Pay:*
Job Duties:*
Reason for Leaving:*
Supervisor Name:*
Telephone: *
May we contact for Reference? *
Employer:
Start Date:
End Date:
Job Title:
Start Pay:
End Pay:
Reason for Leaving:
Supervisor Name:
Telephone:
May we contact for Reference?
Employer:
Start Date:
End Date:
Job Title:
Start Pay:
End Pay:
Reason for Leaving:
Supervisor Name:
Telephone:
May we contact for Reference?

EDUCATION

All applicants will be required to provide proof of education via diploma, degree, transcript, license, and/or certifications.
Name of High School: *
Location of High School: (city and state)*
Did you graduate or receive your GED? *
Highest grade completed?*
College
School:
Major:
GPA:
School:
Major:
GPA:
School:
Major:
GPA:
College degree received:
Degree/Degrees:
Credentials: Check all that apply (transcripts/records must be submitted to verify credentials).
Have you ever lost your state license or received disciplinary actions?*
If yes, please explain in detail:
Have you ever lost or had limitations placed on your hospital privileges (MDs)?
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: *
Ref Phone: *
Ref Name: *
Company Name: *
Email:*
Ref Phone: *
Ref Name:*
Company Name:*
Email: *
Ref Phone:*

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.
Full Name:*
Date:*