Page 1 of 3
APPLICATION
for
EMPLOYMENT
(PLEASE COMPLETE THOROUGHLY, COMPLETELY, AND LEGIBLY)
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the
application and/or interview process should notify a representative of the Human Resources Department.
Position(s) applied for
Date of Application
___
Name
___
LAST
FIRST
MIDDLE
Address
___
STREET
Telephone (
CITY
)
Mobile/Other Phone (
STATE
)
ZIP CODE
Social Security #
___
❏ Yes
If you are under 18, and it is required, can you furnish a work permit?
❏ No
___
If no, please explain
Have you ever been employed here before? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❏ Yes
❏ No
Are you legally eligible for employment in this country? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❏ Yes
❏ No
Date available for work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Type of employment desired
❏ Full Time
❏ Part Time
❏ Temporary
❏ Seasonal
/
❏ Educational Co-Op
Are you able to meet the attendance requirements of the position? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❏ Yes
No Driver’s license number if driving is an essential job function
EMPLOYMENT HISTORY
FROM
TO
Provide the following information for your past FOUR (4) employers, assignments or volunteer activities, starting with the most recent (continue on Page 2):
EMPLOYER
TELEPHONE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
HOURLY RATE/SALARY:
START $
TO
PER
FINAL $
TELEPHONE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
HOURLY RATE/SALARY:
START $
TO
PER
EMPLOYER
JOB TITLE
FROM
❏
___
State
JOB TITLE
FROM
/
PER
FINAL $
PER
EMPLOYER
TELEPHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
HOURLY RATE/SALARY:
START $
PER
FINAL $
PER
2643 Loma Ave. • South El Monte, CA 91733 • (626) 442-0621 • Fax (626) 442-0177
8331 Sierra College Blvd. #220 • Roseville, CA 95661 / 2350 W. Shaw Ave. #135 • Fresno, CA 93711 / 640 E. Vista Way # B • Vista, CA 92084
19153 Town Center Drive #102 • Apple Valley, CA 92308 / 20 N. Sutter Street, #302 • Stockton, CA 95202
Toll-Free (800) 949-4582 • E-Mail: [email protected] • Web Site: www.lincolntc.org
Accredited by the Commission on Accreditation of Rehabilitation Facilities • LTC is a 501(c)(3) not-for-profit organization
Page 2 of 3
APPLICATION
for
EMPLOYMENT
EMPLOYMENT HISTORY Continued from Page 1
FROM
TO
EMPLOYER
TELEPHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
SUMMARIZE THE NATURE OF WORK PERFORMED AND JOB RESPONSIBILITIES
REASON FOR LEAVING
HOURLY RATE/SALARY:
START $
PER
FINAL $
PER
SKILLS & QUALIFICATIONS
Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for
which you are applying:
___
___
___
EDUCATIONAL BACKGROUND IF JOB-RELATED
NAME AND LOCATION
YEARS COMPLETED
DID YOU GRADUATE?
COURSE OF STUDY
HIGH SCHOOL
COLLEGE
MAJOR
DEGREE
OTHER
REFERENCES
NAME
TELEPHONE
(
)
(
)
(
)
YEARS KNOWN
I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM
THE EMPLOYER’S SERVICE, WHENEVER IT IS DISCOVERED.
I GIVE THE EMPLOYER THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION CONTAINED IN THIS
APPLICATION. I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND ITS REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FROM FURNISHING
SUCH INFORMATION.
THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A
BASIS PROHIBITED BY LOCAL, STATE OR FEDERAL LAW.
THIS APPLICATION IS CURRENT FOR ONLY 60 DAYS. AT THE CONCLUSION OF THIS TIME, IF I HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW
APPLICATION.
IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR
WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I
UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER, HAD THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE
IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER.
I UNDERSTAND IT IS THIS COMPANY’S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITY BECAUSE OF THAT PERSON’S NEED FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA.
I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION.
LINCOLN TRAINING CENTER (LTC) COMPLIES WITH ALL FEDERAL, STATE AND MUNICIPAL LAWS WHICH PROHIBIT DISCRIMINATION BECAUSE OF RA CE, COLOR, AGE, RELIGION, SEX, NATIONAL ORIGIN, HANDICAP OR VETERAN STATUS.
PHYSICAL JOB REQUIREMENTS APPROPRIATE TO SOME POSITIONS ARE NECESSARY.
ALL EMPLOYEES ARE EXPECTED TO CONFORM TO THE RULES AND REGULATIONS OF LINCOLN TRAINING CENTER.
I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.
Signature of Applicant
Date
2643 Loma Ave. • South El Monte, CA 91733 • (626) 442-0621 • Fax (626) 442-0177
8331 Sierra College Blvd. #220 • Roseville, CA 95661 / 2350 W. Shaw Ave. #135 • Fresno, CA 93711 / 640 E. Vista Way # B • Vista, CA 92084
19153 Town Center Drive #102 • Apple Valley, CA 92308 / 20 N. Sutter Street, #302 • Stockton, CA 95202
Toll-Free (800) 949-4582 • E-Mail: [email protected] • Web Site: www.lincolntc.org
Accredited by the Commission on Accreditation of Rehabilitation Facilities • LTC is a 501(c)(3) not-for-profit organization
Page 3 of 3
Voluntary Affirmative
Ac tio n Fo rm
In compliance with government regulations we are required to track the number of our applicants
by gender, race/ethnicity, Veteran status and position for which applied. This information will
be kept separately from your application and will be used only in accordance with federal
and state regulations.
You are not required to provide this information. Your application for employment will be
considered in the same manner whether or not you fill out this form.
Gender: ❏ Male ❏ Female
Race/Ethnic Group
□
□
□
□
□
□
White (Not of Hispanic origin): All persons having origins in any of the original peoples of
Europe, North Africa, or Middle East.
Black (Not of Hispanic origin): All persons having origins in any of the black racial groups
of Africa.
Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or
other Spanish culture or origin, regardless of race.
Asian or Pacific Islander: All persons having origins in any of the original peoples of the
Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area
includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.
American Indian or Alaskan Native: All persons having origins in any of the original
peoples of North America, and who maintain cultural identification through tribal affiliation
or community recognition.
Other __________________________________________________________________
Veteran Status:
❏ Not a Veteran
❏ Veteran
❏ Disabled Veteran
❏ Vietnam Era Veteran
Name: ______________________________________________________________________
Date of application: ______________________________
Position applied for: ____________________________________________________________
Referred by: ________________________________________________
How did you learn about the position?
___________________________________________________________________________
2643 Loma Ave. • South El Monte, CA 91733 • (626) 442-0621 • Fax (626) 442-0177
8331 Sierra College Blvd. #220 • Roseville, CA 95661 / 2350 W. Shaw Ave. #135 • Fresno, CA 93711 / 640 E. Vista Way # B • Vista, CA 92084
19153 Town Center Drive #102 • Apple Valley, CA 92308 / 20 N. Sutter Street, #302 • Stockton, CA 95202
Toll-Free (800) 949-4582 • E-Mail: [email protected] • Web Site: www.lincolntc.org
Accredited by the Commission on Accreditation of Rehabilitation Facilities • LTC is a 501(c)(3) not-for-profit organization
Page 4 of 3
Voluntary Affirmative
Ac tio n Fo rm
(Please Specify)
2643 Loma Ave. • South El Monte, CA 91733 • (626) 442-0621 • Fax (626) 442-0177
8331 Sierra College Blvd. #220 • Roseville, CA 95661 / 2350 W. Shaw Ave. #135 • Fresno, CA 93711 / 640 E. Vista Way # B • Vista, CA 92084
19153 Town Center Drive #102 • Apple Valley, CA 92308 / 20 N. Sutter Street, #302 • Stockton, CA 95202
Toll-Free (800) 949-4582 • E-Mail: [email protected] • Web Site: www.lincolntc.org
Accredited by the Commission on Accreditation of Rehabilitation Facilities • LTC is a 501(c)(3) not-for-profit organization