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zack.orwick
2019-05-23T21:44:19+00:00
ImpactLex Employment Application
Applicant Information:
Applying For Location
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Central Kentucky
Northern Kentucky
Applicant Name:
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Main Phone Number(Cell/Home/Work):
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Email Address:
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Number/Street:
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City
*
State
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Zip Code:
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Do You Have a Valid Drivers License?
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Yes
No
Emergency Contact/Phone Number:
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Do You Have Auto Insurance?
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Yes
No
How Did You Hear About Our Agency?
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Legal U.S Citizen?
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Yes
No
Have you lived or worked outside the state of KY in the past 12 months?
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Yes
No
If you answered yes to the previous question, please provide dates and addresses of former out-of-state residence, or employer
Have You Ever Been Convicted of a Felony?
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Yes
No
DUI?
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Yes
No
Employment Position
Position Applying For:
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Are You Applying For?
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Temporary Work(Summer, Holiday, Week-End)
Part-Time(8-20 Weekly Hours)
Full Time(40hrs)
Days Available?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Define Days With Time:
*
Date:
*
Format Should Look As Follows: 00/00/0000
Additional Information:
Upload Your Resume
Drop files here or
Select files
Accepted file types: docx, doc, pdf, Max. file size: 50 MB, Max. files: 5.
Do You Speak Any Foreign Languages?
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Yes
No
If Yes, Describe Experience and level of Fluency?
*
Do you have any experience, training, qualifications or skills which you feel should be brought to our attention, in the case that it would make you especially suited to work for ImpactLex?
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Yes
No
If Yes, Explain, If Not Put N/A:
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What characteristics or abilities do you believe sets you apart from other applicants, and could enhance the lives of the individuals we work with to improve the lives of the people you could potentially be working with?
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Employment History:
Employer/Volunteer Work 1
Dates of Employment 1
Supervisor Name 1
Supervisor phone # 1
Employer/Volunteer Work 2
Dates of Employment 2
Supervisor Name 2
Supervisor phone # 2
Employer/Volunteer Work 3
Dates of Employment 3
Supervisor Name 3
Supervisor phone # 3
Employer/Volunteer Work 4
Dates of Employment 4
Supervisor Name 4
Supervisor phone # 4
Employer/Volunteer Work 5
Dates of Employment 5
Supervisor Name 5
Supervisor phone # 5
Are You Currently Employed?
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Yes
No
May We Contact Previously Listed Employers?
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Yes
No
Education:
Highest Level Of Achieved Education:
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Highschool
College
Other
Elaborate on Level of Education/Other Qualifications:
*
Please Read and Initial Each Paragraph, Then Sign and Date Application:
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission, including any misstatements, of material fact on this application or on any document used to secure can be grounds for rejection of my application or, If I am employed by this company, terms for my immediate termination from the company.
Initial:
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I permit the company to examine my references, records of employment, records of education, and any other information I have provided to include: AOC check, CAN check, KNAR check, TB Test, and First AID/CPR certification. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelations.
Initial:
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Sign and Date:
By typing your full name you comply with all fore mentioned terms and conditions. If full name including middle name is not included, all previous application work will be disregarded.
Signature:
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First/Middle/last
Signature Confirmation:
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First/Middle/Last
Date:
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00/00/0000
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