Employment Application

Demographic Information

No person shall, on the grounds of race, color, national origin, sex, age, creed or handicapping condition be excluded from participation in, be denied benefits, or otherwise be subjected to discrimination, in the provision of any care or service.

First

Middle

Last

Position Applied For

SSN Last 4 XXXX

DOB

Address

Street

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Contact

Home Phone

Cell Phone

Email

Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to this effect should you be employed. For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?

Eligible for Employement:

Yes No

Education

Highest Grade Completed:

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

Last High School Name

Last High School Location

Did you graduate?

Yes No

GED?

N/A Yes No

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Post High School Education / Training

Name

Location

Hours

Degree

Certificate Associates Batchelors Masters PhD

Start

End

Name

Location

Hours

Degree

Certificate Associates Batchelors Masters PhD

Start

End

Name

Location

Hours

Degree

Certificate Associates Batchelors Masters PhD

Start

End

Work History

Starting with the most recent, describe all paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position.

May we contact your present supervisor?

Yes No

Work History 1

Job Title

Type of Business

Phone

Street

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Start Date

End Date

Starting Salary $

Ending Salary $

Number of Employees Supervised:

Work History 2

Job Title

Type of Business

Phone

Street

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Start Date

End Date

Starting Salary $

Ending Salary $

Number of Employees Supervised:

Work History 3

Job Title

Type of Business

Phone

Street

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Start Date

End Date

Starting Salary $

Ending Salary $

Number of Employees Supervised:

Certifications

LIST OTHER TRAINING—LICENSES—CERTIFICATIONS—ACCOMPLISHMENTS:

Do you have any of the following:

Current Certification in First Aid?

Yes No

Current Certification in CPR?

Yes No

Current Certification in Medicaion Administration?

Yes No

Current Certification in Behavior Management?

Yes No

Current Drivers License?

Yes No

Current TB (PPD) Screening?

Yes No

NOTE: Copies of these certifications must be provided to the Director of Human Resources if a job offer is extended to you.

Miscellaneous

Shifts you are willing to accept:

Day Evening Midnight Weekends

Job status you are willing to accept:

Full Time Part Time

How would you get to work?

Own Car Bus Friend Walk

Employment References

Work Reference 1

Job Title

Type of Business

Phone

Street

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Work Reference 2

Job Title

Type of Business

Phone

Street

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Work Reference 3

Job Title

Type of Business

Phone

Street

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Certification

By typing my full name below, I hereby certify that all statements made in this application are true and complete to the best of my knowledge. I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment opportunities with LUCAS LODGE, LLC and persons named herein blameless in that event. I understand that all information on this application is subject to verification and I consent to references and former employers and educational institutions and licensing boards listed being contacted regarding this application.

Full Name Signture

Date