LifeNet Application For Employment

Complete this application and mail or fax to:

Mandi Smith
Director Of Human Resources
LifeNet EMS
6300 Hampton Road
Texarkana, Texas 75503
Fax: 903-832-0215

Basic Information
Position Applied For:

_____________________________________________________

Date of Application:

_____________________________________________________

Referral Source:

  • Advertisement
  • Walk-in
  • Employee
  • Private Employment Agency
  • Relative
  • Web Site
  • Government Employee Agency
  • Other

  Name of Source (if applicable) __________________
Name:

Last________________  First_______________  Middle_________

Social Security Number: ___________________
Address:

Street__________________________________________________

City____________________  State_________  Zip_____________
Home Telephone:

(_____) _____ - __________

If necessary, best time to contact you at home is:

__________________________________________
Work Telephone:

(_____) _____ - __________

May we contact you at work ?    __________ (Yes/No)

If Yes, what is the best time to contact you ?    _______________
Other:

If you are under 18, can you furnish a work permit ?  _________ (Yes/No)

If you filed an application here before ?   _________ (Yes/No)

If yes, give date: ______ / _______ / _______

Have you ever been employed here before ?    __________ (Yes/No)

If yes, give dates: ______ / ______ / ______   to  ______ / ______ / ______

Are you legally eligible for employment in this country ? ___________ (Yes/No)

(proof of U.S. Citizenship or immagration status will be required upon employment)

Date available for work: _______ / _______ / _______

Type of employment desired:

  • Full Time
  • Part Time
  • Temporary

Are you on lay-off and subject to recall ?   __________ (Yes/No)

Will you relocate if job requires it ?   __________ (Yes/No)

Will you travel if job requires it ?   __________ (Yes/No)

Are you able to meet the attendance requirements of this position ? __________ (Yes/No)

Will you work overtime if required ?   __________ (Yes/No)

Have you ever been bonded ?  __________ (Yes/No)

Have you been convicted of a felony in the last seven (7) years  ?  __________ (Yes/No)

(such conviction may be relevant if job related, but does not bar you from employment)

If yes to felony, please explain: _______________________________________

__________________________________________________________________

Driver's License Number: ________________  State _________
Employment History
List your last four (4) employers, assignments, or volunteer activities, starting with the most recent.  Include military experience.  Explain any gaps in employment in the comments section below.
Employer: ____________________________________

Address:_______________________________________

Telephone: _____________________________________

Job Title: _______________________________________

Immediate Supervisor & Title:

_______________________________________________

Reason for Leaving

_______________________________________________

May we contact for reference ? __________ (Yes/No/Later)

 Dates Employed:

From _____/_____/_____ to _____/_____/_____

Hourly Rates:

Starting:  $____________ per ____________

Ending:    $____________ per ____________

Summarize the nature of the work performed and job responsibilities:

____________________________________________

____________________________________________

____________________________________________

____________________________________________
 

Employer: ____________________________________

Address:_______________________________________

Telephone: _____________________________________

Job Title: _______________________________________

Immediate Supervisor & Title:

_______________________________________________

Reason for Leaving

_______________________________________________

May we contact for reference ? __________ (Yes/No/Later)

  

Dates Employed:

From _____/_____/_____ to _____/_____/_____

Hourly Rates:

Starting:  $____________ per ____________

Ending:    $____________ per ____________

Summarize the nature of the work performed and job responsibilities:

____________________________________________

____________________________________________

____________________________________________

____________________________________________
 

Employer: ____________________________________

Address:_______________________________________

Telephone: _____________________________________

Job Title: _______________________________________

Immediate Supervisor & Title:

_______________________________________________

Reason for Leaving

_______________________________________________

May we contact for reference ? __________ (Yes/No/Later)

  

Dates Employed:

From _____/_____/_____ to _____/_____/_____

Hourly Rates:

Starting:  $____________ per ____________

Ending:    $____________ per ____________

Summarize the nature of the work performed and job responsibilities:

____________________________________________

____________________________________________

____________________________________________

____________________________________________
 

Employer: ____________________________________

Address:_______________________________________

Telephone: _____________________________________

Job Title: _______________________________________

Immediate Supervisor & Title:

_______________________________________________

Reason for Leaving

_______________________________________________

May we contact for reference ? __________ (Yes/No/Later)

  

Dates Employed:

From _____/_____/_____ to _____/_____/_____

Hourly Rates:

Starting:  $____________ per ____________

Ending:    $____________ per ____________

Summarize the nature of the work performed and job responsibilities:

____________________________________________

____________________________________________

____________________________________________

____________________________________________
Comments (include explanation of any gaps in employemetn):_____________________________________

________________________________________________________________________________________
Educational Background
List the last three (3) schools attended, starting with the most recent.  List number of years completed, degree or diploma earned (if any), and major and minor of study (if applicable).
School Years Completed Degree / Diploma Major Minor
_________________________ __________ _______________ ____________ _____________
_________________________ __________ _______________ ____________ _____________
_________________________ __________ _______________ ____________ _____________
List any foreign language(s) you know and check the boxes that describe your skill level.
Language Speak Some Speak Fluently Read Write
_________________________ __________ _______________ ____________ _____________
_________________________ __________ _______________ ____________ _____________
_________________________ __________ _______________ ____________ _____________
References
List three (3) business work references who are not related to you and are not previous supervisors.  If not applicable, list three (3) school or personal references who are not related to you.
Name Telephone Years Known
_______________________________

(____) ___________

 ______________
_______________________________

(____)____________

 ______________
_______________________________

(____)____________

 ______________

List professional, trade, business, or civic associations and any offices held.  (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)
Organization Offices Held
_______________________________ ____________________________________________
_______________________________ ____________________________________________
_______________________________ ____________________________________________
List special accomplishments, publications, awards.  (Exclude information which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
List any additional information you would like us to consider. (special skills, qualifications, experiences)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Conclusion
It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed.

I give the Employer the right to investigate all references and to secure additional information about me, if job related.   I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.

The Employer is an Equal Opportunity Employer.  The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.

I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice.  I understand that no representative of the Employer has the authority to make any assurances to the contrary.

Signature of Applicant: ________________________________     Date: _______/_______/_______