EMPLOYMENT - ImpactLex | Personal Care & Community Living Support Services

ImpactLex Employment Application

Applicant Information:
Applicant Name:*
Main Phone Number(Cell/Home/Work):*
Email Address:*
Number/Street:*
City*
State*
Zip Code:*
Do You Have a Valid Drivers License?*
Emergency Contact/Phone Number:*
Do You Have Auto Insurance?*
How Did You Hear About Our Agency?*
Legal U.S Citizen?*
Have you lived or worked outside the state of KY in the past 12 months?*
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?*
DUI?*
Employment Position
Position Applying For:*
Are You Applying For?*
Days Available?*
Define Days With Time:*
Date:*
Format Should Look As Follows: 00/00/0000
Additional Information:
Do You Speak Any Foreign Languages?*
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?*
If Yes, Explain, If Not Put N/A:*
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?*
Employment History:
Are You Currently Employed?*
List Previous Employers Dating back five years:*
Format Should Look As Follows: Name of Employer: Name of Supervisor: Telephone Number: Business Type: Address: City, State, Zip: Date of Employment(EX. 05-14-06-14) Position and Duties: Reason For Leave:
May We Contact Previously Listed Employers?*
References:*
List Up To Three References That We May Contact: Should Look as Follows: Name: Telephone: Address: City,State,Zip: Number of Years Known:
Education:
Highest Level Of Achieved Education:*
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:*
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:*
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:*
First/Middle/last
Signature Confirmation:*
First/Middle/Last
Date:*
00/00/0000

ImpactLex Employment Application

Applicant Information:

Employment Position

Additional Information:

Employment History:

Education:

Please Read and Initial Each Paragraph, Then Sign and Date Application:

Sign and Date: