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Employment Application

Applicant Information

Full Name:      
Last: Required Field First: Required Field
M.I.: Date:
Required FieldMust be a Date mm/dd/yyyy
Address:      
Street Address:
Required Field		 Apartment/Unit#
Required Field
City:
Required Field		 State:
Required Field
ZIP Code:    
Phone:
Required Field		 E-mail Address:
Required Field
Must be a valid email adress
Date Available: Desired Salary:$
Position Applied for:
Are you authorized to work in the United States?
Select one option
Have you ever worked for this company?
Select one option
If yes, when?
Have you ever been convicted of a felony?
Select one option
Have you ever been convicted of a crime/misdemeanor other than a felony?
Select one option
If yes, explain:

Per Diem and Part Time Positions: State the shifts, days, and hours you are available to work: (note – changes to schedule must be discussed with Residence Manager with at least two weeks prior notice)

Education

High School: Address:
Did you graduate?
Degree:
College: Address:
Did you graduate? Degree:
Other: Address:

References

Please list three professional references.
Full Name: Relationship:
Company: Phone:
Address:    
Full Name: Relationship:
Company: Phone:
Address:    
Full Name: Relationship:
Company: Phone:
Address:    

Previous Employment

Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
From: To:
Reason for Leaving:    
May we contact your previous supervisor for a reference?
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
From: To:
Reason for Leaving:    
May we contact your previous supervisor for a reference?
Company: Phone:
Address: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
From: To:
Reason for Leaving:    
May we contact your previous supervisor for a reference?

Military Service

Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:

Disclaimer

Applicant Questionnaire

1. During the last 24 months at your previous place of employment, how many times were you absent from work for reasons unrelated to a disability you may have, your own serious health condition or to care for a child, spouse, parent, or dependent grandparent with a serious health condition?
 
2. During the last 24 months at your previous place of employment, how many times were you late from work for reasons unrelated to a disability you may have, your own serious health condition or to care for a child, spouse, parent, or dependent grandparent with a serious health condition?
 
3. In the last 24 months at your previous place of employment, how many times were you disciplined?  For each disciplinary action, please list the reason and the employer who disciplined you.
  Required Field
 
a. If you were disciplined, was the disciplinary action justified by the employer?
Select one option
b. If you believe that any or all of the disciplinary actions taken against you were not justified, please list each and describe your reasons in detail.
  Required Field
4. Why do you want to work at LIFESKILLS SOUTH FLORIDA?  And, what position(s) do you feel you are best suitable for?  And, why?
 
5. Is there any additional information which you feel LIFESKILLS SOUTH FLORIDA should consider in connection with your employment application?
 

Terms and Conditions

Provision of the following information is voluntary and a refusal to provide such information will not have any effect on the company's employment decision.  In addition, applicants areconsidered for positions without regard to race, color, region, sex, national origin, sexual preference, age, marital status, medical condition, disability, or other legally protected status.

 

LIFESKILLS SOUTH FLORIDA utilizes a sophisticated and detailed background and pre-employment investigation process. This process frequently discloses inaccurate, false, and/or incomplete or omitted information. Should this process determine any inaccurate or incomplete information, it will result in you either being disqualified from employment with LIFESKILLS SOUTH FLORIDA as an applicant, or it will result in termination if the inaccuracies are discovered subsequent to your employment with LIFESKILLS SOUTH FLORIDA.  Accordingly, LIFESKILLS SOUTH FLORIDA strongly suggests that you NOT complete this application until you have the time and accurate information to do so. 

 

LIFESKILLS SOUTH FLORIDA is an equal opportunity employer and will not discriminate against any employee or applicant for employment in any manner prohibited by law.  If you feel you have been unfairly treated or discriminated against for any reason, please call this to the attention of Director of Human Resources so that we may address your concerns.

 

Employment is conditional on the successful completion of the screening process. By signing this application, I (applicant’s name printed)       , represent that the information provided in this form is given voluntarily, may be used in filing reports required by state and federal governments and agencies, may be disclosed to others and used for any other purpose not prohibited by law.  LIFESKILLS SOUTH FLORIDA requires that all individuals who successfully complete the initial employment screening process to submit to a drug screening program, which may include the taking of blood, urine, hair audio other body samples, and [requires\reserves the right to require] that all employees submit to drug and alcohol testing during the course of their employment.  The result of such screening and testing will be initially disclosed to decision makers for LIFESKILLS SOUTH FLORIDA and may be the basis for disqualifying any candidate for employment and for termination during employment.  LIFESKILLS SOUTH FLORIDA reserves the right to utilize this information in any way it deems necessary, such as but not limited to civil, criminal and administrative proceedings, and any other similar matters. 

 

THE FOLLOWING IS A DECLARATION THAT IS UNDERSTOOD
AND AGREED UPON BY ALL PARTIES

 

I UNDERSTAND that this application will only be considered "active” for 30 calendar days from the date of application.  If I have not obtained employment with LIFESKILLS SOUTH FLORIDA within 30 days, but remain interested in obtaining employment with LIFESKILLS SOUTH FLORIDA.  I understand that I must complete a new application/notify LIFESKILLS SOUTH FLORIDA, in writing of my desire for my application to be considered for an additional 30 days.

 

I ALSO UNDERSTAND that all statements made by me in connection with my application for employment may be checked by LIFESKILLS SOUTH FLORIDA.  I authorize LIFESKILLS SOUTH FLORIDA to contact my prior employers, including each of those employers listed, and other sources of information, regarding my background, and I hereby authorize and direct each such employer and source of information to answer any and all questions regarding my prior employment and background.  I hereby agree to indemnify LIFESKILLS SOUTH FLORIDA, each of my prior employers listed, and each of the other sources of information contacted, and further agree to hold each and every one of them harmless from any claims arising from this authorization and direction.  I also authorize LIFESKILLS SOUTH FLORIDA to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information.

 

I UNDERSTAND further that any misstatements or omissions in this application will result in a decision not to hire me, or to discharge me if discovered only after hire.


I UNDERSTAND to be eligible for employment at LIFESKILLS SOUTH FLORIDA; recovering individuals must be at least two years clean and sober.


If EMPLOYED, I agree to conform to the rules and regulations of LIFESKILLS SOUTH FLORIDA, I understand that as a condition of my employment and continued employment, I will be required to submit to, and do voluntarily agree to submit to any testing for the presence of drugs or alcohol, and to submit to any, procedure to assess my qualifications for employment.

 
I ALSO AGREE that, just as I have, if hired, the right to terminate my employment at any time, with or without cause, and with or without notice, LIFESKILLS SOUTH FLORIDA, may terminate my employment at any time with or without cause or notice.  I understand that no manager or representative of other than the President LIFESKILLS SOUHT FLORIDA, has any authority to enter into any agreement for employment for any specified period of time, or make  any agreement contrary to the foregoing either now, in the past or the future.  I further understand that every such an agreement must be in writing and signed by the President for it to be binding on either myself or LIFESKILLS SOUTH FLORIDA.  I further understand that this supersedes any prior oral or written understanding and bats any future oral understanding to the contrary.


I ACKNOWLEDGE and AGREE that if at any time during the hiring process or during my employment I am subjected to any type of discrimination or harassment, I will contact LIFESKILLS SOUTH FLORIDA Human Resource Director immediately to obtain assistance in the resolution of such matters.


In recognition of the fact that any work related injuries which might be sustained by me may be covered by state Workers' Compensation statutes, and to avoid the circumvention of such state statutes which may result from suits against the customers or clients of LIFESKILLS SOUTH FLORIDA company based on the same injury or injuries, and to the extent permitted by law, I HEREBY WAIVE AND FOREVER RELEASE ANY RIGHTS I MIGHT HAVE to make claims or bring suit against any client or customer of LIFESKILLS SOUTH FLORIDA company for damages based upon injuries which are covered under such Workers' Compensation statutes.


I FURTHER ACKNOWLEDGE and AGREE that any dispute between myself and LIFESKILLS SOUTH FLORIDA relating to my application for employment, my employment, if hired, and/or the separation of thereof, which cannot be resolved informally, shall be resolved pursuant to the voluntary labor arbitration rules of the American Arbitration Association ("AAA”) in Palm Beach County, FL, by an impartial arbitrator, selected in accordance with such rules, asthe exclusive remedy for any such dispute, including but not limited to claims of alleged discrimination.  I understand that I must submit any claim to arbitration no later than 365 calendar days following the date I became aware of the conduct constituting the alleged claim.  I agree to waive my right to a jury trial over any such dispute and agree the failureto timely submit any claim to arbitration shall result in a waiver of thealleged claim.  I further agree to waive any and all claims not raised through this procedure. I understand that this provision does not preclude me fromfiling a complaint or charge of discrimination with any federal, state or local agency.


I HEREBY REPRESENT AND WARRANT that I have read and fully understand the foregoing and seek employment under these conditions of my own free will and in accordance with my own judgment. 


I HEREBY CERTIFY THAT the information contained in this submission is correct and complete to the best of my knowledge, understand and agree that falsification of this information or a material omission may disqualify me from further consideration for employment and is grounds for termination of employment with LIFESKILLS SOUTH FLORIDA any time.  By signing this application, I agree to the foregoing and further agree to hold LIFESKILLS SOUTH FLORIDA harmless for any claims resulting from such screening and testing for drug and/or alcohol use.