| Personal Information |
|
|
|
| |
Name:
|
|
|
Address:
|
| |
City:
|
|
|
State:
|
| |
Zip:
|
|
|
E-Mail:
|
| |
Phone:
|
|
|
Work:
|
| |
Cell:
|
|
|
Gender:
Male
Female |
| |
Are you at least 18 years of age?:
Yes
No |
| |
Do you have authorization to work in U.S. on a full time
continuous basis? (I-9 Required)
Yes
No |
| |
Emergency Contact:
|
|
|
Emergency Phone:
|
| |
Position(s) You are interested in::
|
|
|
Skills, Interests and Hobbies:
|
|
Educational Information |
| |
Highest level of education completed:
|
|
|
Additional education and/or training:
|
|
|
Name and Location of College/University, Graduate
School, Course of Study, Number of years completed,
Diploma or Degree Received:
|
|
|
Professional Licenses or certificates held and date of
expiration:
|
|
|
Office Skills / software experience:
|
|
|
Professional, trade, business or civic memberships
or activities:
|
|
Employment Information |
| |
Current employment status:
|
| |
Name of Employer:
|
|
|
Job Title:
|
| |
Address of Employer:
|
| |
Dates Employed:
|
|
|
Name of Supervisor:
|
| |
Reason for Leaving:
|
| |
May we contact your present employer at this time?
Yes
No |
| |
Previous Employer's Name:
|
|
|
Job Title:
|
| |
Address of Employer:
|
| |
Dates Employed:
|
|
|
Name of Supervisor:
|
| |
Reason for Leaving:
|
| |
Previous Employer's Name:
|
|
|
Job Title:
|
| |
Address of Employer:
|
| |
Dates Employed:
|
|
|
Name of Supervisor:
|
| |
Reason for Leaving:
|
| |
Previous Employer's Name:
|
|
|
Job Title:
|
| |
Address of Employer:
|
| |
Dates Employed:
|
|
|
Name of Supervisor:
|
| |
Reason for Leaving:
|
| |
Previous Employer's Name:
|
|
|
Job Title:
|
| |
Address of Employer:
|
| |
Dates Employed:
|
|
|
Name of Supervisor:
|
| |
Reason for Leaving:
|
|
Related Experience and Training
|
|
|
Previous experience including location and dates:
|
|
Have you taken ContactLifeline training in the past?
Yes
No
|
| |
If so, when?
|
|
|
Where?
|
|
|
Write a brief statement explaining your
desire to work for ContactLifeline:
|
|
|
What are your strengths and limitations
relating to people in distress or crisis?
|
|
Background Verification |
|
Have you ever been convicted
of a criminal offense?
|
Yes
No |
|
Have you ever been charged
with neglect, abuse, or
assault?
|
Yes
No |
|
Has your driver’s license ever
been suspended or revoked in
any state?
|
Yes
No |
|
Do you use illegal drugs?
|
Yes
No |
|
Do you have any physical
limitations which might limit
your ability to perform
certain types of work?
|
Yes
No |
|
Background Checks will be performed before active service.
A criminal conviction or other disclosures will not necessarily be a bar to employment. ContactLifeline is subject to state and federal law that may limit the ability to extend employment to persons convicted of certain offenses. |
References
|
|
List name and phone numbers of two
personal and/or professional references:
|
| |
Reference Name 1:
|
|
|
Phone:
|
|
|
How many years known and in what capacity?
|
| |
|
|
|
|
| |
Reference Name 2:
|
|
|
Phone:
|
|
|
How many years known and in what capacity?
|
| |
|
|
|
|
| |
Reference Name 3:
|
|
|
Phone:
|
|
|
How many years known and in what capacity?
|
|
Applicant’s Statement |
|
I have read and agree to the statements below:
I understand that any misstatement, omission, or misleading information given in my application, resume, or interview or in connection with any other ContactLifeline records may result in the rejection of my application, the withdrawal of any offer of employment or my dismissal.
I authorize the investigation of all statements contained in this application for employment. I give permission to contact any or all of my previous employers and references and authorize them to provide all information requested of them.
I acknowledge that due to the nature of the position for which I am applying and the agency, that ContactLifeline reserves the right to conduct criminal history and background investigations as required under law or ContactLifeline’s personnel policies.
|
|
Referral Source |
|
|
|
|
|
|
|
|
|
|
Applicants may also print and submit this application to
ContactLifeline by...
Postal Mail:
ContactLifeline, Inc.
P.O. Box 9525
Wilmington, DE 19809
Attn: Employment
Fax to:
(302) 761-4280
Please submit separate pages for lengthy
responses. Printed versions of this form omit responses that
exceed field limits. |
