Employment Application

Lifeway Services, LLC does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.

If any of the following questions are not answered in a complete and accurate fashion, a significant delay and/or the inability to process this application may occur.

Date

Last Name *

First Name *

Maiden/Prior Aliases

Address *

Email *

City *

State *

Zip Code *

Home Phone Number

Mobile Phone Number *

Social Security Number

Date of Birth *

Which position are you appying for?

Available to Work *

Full Time

Part Time

Temporary

Which location?

If temporary, explain

Are there any days or hours you would be unable or unwilling to work?

No

Yes

If yes, explain

Date Available to Start:

How did you hear about Lifeway Services?

Have you lived outside the state of Pennsylvania within the last 2 years? *

No

Yes

Have you ever filed an application or been employed with another provider service agency? *

No

Yes

If yes, give entity and date(s)

Do you have the legal right to be employed in the United States? *

No

Yes

Have you signed a restrictive covenant/non-compete agreement or confidentiality statement at a prior job? *

No

Yes

If yes, please explain:

Have you ever been disciplined or discharged by an employer for client abuse or neglect? *

No

Yes

If yes, please explain:

Have you ever been convicted, (or plead guilty) of any crime (felony, misdemeanor, or summary offense)? Please include any incidence of driving while intoxicated. *

No

Yes

If yes, please explain:

(Information regarding convictions will not necessarily disqualify you for employment, but will be reviewed in light of the duties and responsibilities of the position being sought)

Driver's License Number *

State Issued *

Currently Valid? *

No

Yes

A valid licenses, good driving history, and proof of insurance are required for many positions

Education

High School

Name

Address

Years Completed

1

2

3

4

Major

Graduated?

No

Yes

Degree

Undergraduate College

Name

Address

Years Completed

1

2

3

4

Major

Graduated?

No

Yes

Degree

Graduate/Professional

Name

Address

Years Completed

1

2

3

4

Major

Graduated?

No

Yes

Degree

Work History

List the name of all employers, giving the most recent position first.

Employer Name

Address

Phone Number

Supervisor

Dates Employed From (mo/yr)

Salary Started

Job Title

Reason For Leaving

To (mo/yr)

Salary Ended

Duties

Employer Name

Address

Phone Number

Supervisor

Dates Employed From (mo/yr)

Salary Started

Job Title

Reason For Leaving

To (mo/yr)

Salary Ended

Duties

Employer Name

Address

Phone Number

Supervisor

Dates Employed From (mo/yr)

Salary Started

Job Title

Reason For Leaving

To (mo/yr)

Salary Ended

Duties

Employer Name

Address

Phone Number

Supervisor

Dates Employed From (mo/yr)

Salary Started

Job Title

Reason For Leaving

To (mo/yr)

Salary Ended

Duties

Professional License and/or Certification

List any professional licenses

License Number

Has your professional licenses ever been suspended or revoked?

No

Yes

If yes, please explain

Please list any other qualifications, professional organizations, and/or volunteer experiences that are applicable to the position for which you are applying.

References

If you have worked for previous employers under another name, please give that name:

Are you currently employed? *

No

Yes

If yes, may we contact your present employer?

No

Yes

Give two work related references:

Name

Address

Phone Number

Occupation

Name

Address

Phone Number

Occupation

Emergency Contact

Name *

Address *

Phone Number

Email

Relationship *

Availability

Number of hours per week minimum/maximum that I am willing to work: *

Are you available all days and hours?

No

Yes

If no, what days and times are you available to work?

Direct Care Worker

Agreement of Hours To Work

If offered a position as a Direct Care Professional, I agree to be available for scheduling the following days and times. I understand that I must work a minimum number of hours (agreed upon by management) to maintain employment status at Lifeway Services LLC, as a Direct Care Professional. I understand that by committing to and signing this agreement I will be given a schedule that is suitable to what I have indicated below as a new employee with Lifeway Services LLC. I also understand that if I refuse to accept a schedule that I have stated I am available for, I will risk not being assigned any hours to work for an unspecified period of time as it may also lead to being separated as a Lifeway Services LLC employee if there are no available hours. I understand that I cannot request a change of my availability during the 90 day probationary period. After the 90 day probation period, as a Direct Care Professional, if my schedule availability were to change (i.e., for reasons such as school, scheduling, another job, etc.) I understand that a formal request must be made and approved by management. However, I would continue to remain committed to work the schedule that I would be given initially until such changes would be approved.

A face-to-face interview will be conducted on all potential employees prior to being hired. Additional interviews may be required before a position may be offered to an applicant. Please bring a copy of the following to the interview:

Social Security Card

Driver's License/Photo ID

Auto Insurance card/level of coverage

Any training certificates/competency trainings

Prior work-related experiences

Intellectual Disability work experience

If you would like to submit a resume or any other supporting documentation, you may email it to jmcintyre@mylifewayservices.com .

I have read and understand the contents of this application. (Your initials)

Name

Employment Application

Employment Application

Lifeway Services, LLC does not discriminate on the basis of race, color, national origin, ancestry, religious creed, handicap, or age as stated in the Pennsylvania Human Relations Act of 1955.

If any of the following questions are not answered in a complete and accurate fashion, a significant delay and/or the inability to process this application may occur.

(Information regarding convictions will not necessarily disqualify you for employment, but will be reviewed in light of the duties and responsibilities of the position being sought)

*A valid licenses, good driving history, and proof of insurance are required for many positions*

Education

High School

Undergraduate College

Graduate/Professional

Work History

List the name of all employers, giving the most recent position first.

Professional License and/or Certification

References

Give two work related references:

Emergency Contact

Availability

Direct Care Worker Agreement of Hours To Work

A valid licenses, good driving history, and proof of insurance are required for many positions

Direct Care Worker

Agreement of Hours To Work