LifeStart, Inc., Central Ohio Foster Care Agency


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Application for Employment


LifeStart, Inc. is an Equal Opportunity Employer
All sections/blanks on the application must be completed.
 

PERSONAL INFORMATION
Position Desired:
Name:
First Middle Last
E-mail Address:
Address:
City State ZIP
Home Phone: (including area code)
Cell Phone: (including area code)
Do you want to work full-time? Yes    No
Do you want to work part-time? Yes    No
When will you be available
to begin work:		 (Today is 7/4/2022)
Are you legally eligible for
employment in the United States?		 Yes    No
Are you currently employed: Yes    No
       If Yes, may we contact
       your present employer?		 Yes    No
       If No, please explain:

AVAILABILITY SCHEDULE
Please check the boxes below to indicate your availability for work on that day/time.  Leave non-available days/times unchecked.

Click day to check entire day:

 Mon Tue Wed Thu Fri Sat Sun

MIDNIGHT

 12 AM - 1 AM
  1 AM - 2 AM
  2 AM - 3 AM
  3 AM - 4 AM
  4 AM - 5 AM
  5 AM - 6 AM

MORNING

 6 AM - 7 AM
  7 AM - 8 AM
  8 AM - 9 AM
  9 AM - 10 AM
  10 AM - 11 AM
  11 AM - 12 PM

NOON

 12 PM - 1 PM
  1 PM - 2 PM
  2 PM - 3 PM
  3 PM - 4 PM
  4 PM - 5 PM
  5 PM - 6 PM

NIGHT

 6 PM - 7 PM
  7 PM - 8 PM
  8 PM -  9 PM
  9 PM - 10 PM
  10 PM - 11 PM
  11 PM - 12 AM

EDUCATIONAL INFORMATION
Please complete all applicable fields.  Leave non-applicable fields blank.

Graduate
School Name
Location
Course of Study
# of Years Completed Years
Did you Graduate? Yes    No
Degree Diploma (e.g. MA, MBA, Ph.D.)
College
School Name
Location
Course of Study
# of Years Completed Years
Did you Graduate? Yes    No
Degree Diploma (e.g. BS, BA, BFA)
Business, Trade, or Technical
School Name
Location
Course of Study
# of Years Completed Years
Did you Graduate? Yes    No
Degree Diploma (e.g. Associates)
High School
School Name
Location
# of Years Completed Years
Did you Graduate? Yes    No
Junior/Middle
School Name
Location
# of Years Completed Years
Elementary
School Name
Location
# of Years Completed Years

SPECIAL SKILLS & QUALIFICATIONS
Summarize special job-related skills and qualifications acquired from employment or other experiences.

LIST PROFESSIONAL, TRADE, BUSINESS, OR CIVIC ACTIVITIES AND OFFICES HELD.  ALSO LIST ALL VOLUNTARY TIME
You may exclude memberships which would reveal sex, race, religion, national origin, ancestry, handicap, or other protected status.

REFERENCES
Give name and telephone number of four references who have credentials, licenses, or are community leaders such as teachers, coaches, religious leaders, or club leaders.

  Name Title/Relation Telephone Number
1)
2)
3)
4)

EMPLOYMENT HISTORY
Please give complete full-time and part-time employment record.  Start with your present or most recent employer.  Please explain any gaps in employment.

       
1)  Employed From to    
     Job Title Hourly or Monthly Pay to
       
     Company Name Telephone
     Supervisor Name
 
 		 Address
(with City, State, ZIP)
       
     Describe Your Work

 

 Reason for Leaving

 
       
       
2)  Employed From to    
     Job Title Hourly or Monthly Pay to
       
     Company Name Telephone
     Supervisor Name
 
 		 Address
(with City, State, ZIP)
       
     Describe Your Work

 

 Reason for Leaving

 
       
       
3)  Employed From to    
     Job Title Hourly or Monthly Pay to
       
     Company Name Telephone
     Supervisor Name
 
 		 Address
(with City, State, ZIP)
       
     Describe Your Work

 

 Reason for Leaving

 
       
       
4)  Employed From to    
     Job Title Hourly or Monthly Pay to
       
     Company Name Telephone
     Supervisor Name
 
 		 Address
(with City, State, ZIP)
       
     Describe Your Work

 

 Reason for Leaving

 
       
       
5)  Employed From to    
     Job Title Hourly or Monthly Pay to
       
     Company Name Telephone
     Supervisor Name
 
 		 Address
(with City, State, ZIP)
       
     Describe Your Work

 

 Reason for Leaving

 
       

CRIMINAL AND DRIVING RECORD

Have you ever been arrested?
     If Yes, please explain:
    

Yes    No
(does not necessarily prohibit employment)
Have you ever been convicted of
any crime, misdemeanor, or felony?
     If Yes, please explain:
    


Yes    No
Do you have a clean driving record?
(does not necessarily prohibit employment)

Yes    No
      If No, how many points do you have on your driving record?

Have you been an Ohio resident for the past five years?

Yes    No
Have you been convicted of or pleaded guilty to any disqualifying offenses?

Yes    No
Will you notify employer in writing within 14 days if you are formally charged with, convicted of, or plead guilty to any disqualifying offenses?

Yes    No

STATEMENT OF AUTHENTICITY

I confirm that information provided on this Application for Employment is true, correct, and complete.  If employed, any misstatement or omission of fact on this application may result in my dismissal.

I understand that terms of my employment will be based on a positive background check and fingerprinting results from the Bureau of Criminal Investigation and Identification, reference checks, and driver safety records.

Date            Signature 
          Today is 7/4/2022                 Type Name to Serve as Signature

Verification Word:
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