Address: 7018 Elmwood Ave Philadelphia, Pa 19142
Office: 2153652500
Email: hr@lifetservices.org
Office Hours: 9am - 5pm
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EMPLOYMENT APPLICATION
Date Of Birth
(Required)
MM slash DD slash YYYY
Name:
(Required)
First Name
Last Name
Address: (Please include city, state and zip code)
(Required)
Cell Phone:
(Required)
Email:
(Required)
Personal Information
Have you ever applied to or worked for Lifetime Skills Home Healthcare Services? To where we have Untitled (Referral)
Previously Applied
Previously Employed
Neither
If YES, when did you apply?
(Required)
MM slash DD slash YYYY
How did you learn about LSHS?
(Required)
On-Line Advertisement
Walk-In
Website
Referral
Other
Untitled
Do you have any friends or relatives working for LSHS?
(Required)
Yes
No
Have you lived outside of the state of Pennsylvania within the last two years?
(Required)
Yes
No
Are you 18 years of age or over? *
(Required)
Yes
No
Are you legally eligible to work in the United States?
(Required)
Yes
No
Can you show proof of citizenship/visa/alien registration if we decide to hire you?
(Required)
Yes
No
Do you have any experience, training, qualifications or skills, which you feel make you especially suited for work at Lifetime Skills Home Heathcare Services Foundation?
(Required)
Yes
No
Explain the skill or training you have
(Required)
If required by this Agency, are you willing to undergo a criminal record check as part of this application process?
(Required)
Yes
No
Driver's License Information
Do you have a valid driver's license?
(Required)
Yes
No
*** If the position you are applying for requires a Driver's License, please make sure you have it available to present it at the time of the interview ***
Employment Desired
Position applying for:
(Required)
Direct Support Professional (DSP)
CNA
Caregiver
Supervisor
I certify that my availability to work is as I have stated upon this application. Any variation in this availability prior to hire, upon hire or during the course of employment with LSHS will impact my eligibility for employment or continued employment. I am responsible to accurately provide my work availability on this application, during any process and if I am employed.*
Are you applying for:
(Required)
Full-Time Work
Part-Time Work
On-Call Work
Temporary Work, e.g., Summer or Holiday Work
If you selected "other availability" above, please indicate the days and hours of availability for each day below:
(Required)
7 am – 3 pm
3 pm – 11 pm
11 pm – 7 am
7 am – 7 pm
7 pm – 7 am
Select Day
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Select Day
(Required)
Saturday
Sunday
Are you available to work in a back-up capacity/pick up open shifts?
(Required)
Yes
No
Your shift may fall on a Holiday and if so, it is our policy that you work that shift. Will that be a challenge for you?
(Required)
Yes
No
If hired, on what date can you start work?
(Required)
MM slash DD slash YYYY
If hired, do you a reliable means of transportation to work?
(Required)
Yes
No
Education, Training and Experience
Name of High School:
(Required)
Address: (Please include city, state and zip code)
(Required)
Did you Graduate?
(Required)
Yes
No
Diploma or GED?
(Required)
Diploma
GED
Name Of The Degree
Did you attend a College/ University?
(Required)
Yes
No
Name of College/University:
(Required)
Address: (Please include city, state and zip code)
(Required)
Did you Graduate?
Yes
No
College Degree:
(Required)
Company Name #1
(Required)
Address: (Please include city, state and zip code)
(Required)
Supervisor's Name:
(Required)
First
Last
Telephone Number:
(Required)
Position:
(Required)
Job Duties:
(Required)
Start Date of Employment:
(Required)
MM slash DD slash YYYY
Are you still currently employed?
(Required)
Yes
No
End Date of Employment
MM slash DD slash YYYY
Reason for Leaving:
(Required)
May we contact this employer for a reference?
Yes
No
Company Name #2
(Required)
Address: (Please include city, state and zip code)
(Required)
Supervisor's Name
(Required)
First
Last
Telephone Number
(Required)
Position
(Required)
Job Duties:
(Required)
Start Date of Employment
(Required)
MM slash DD slash YYYY
Are you still currently employed?
Yes
No
End Date of Employment
(Required)
MM slash DD slash YYYY
Reason for Leaving
(Required)
May we contact this employer for a reference?
(Required)
Yes
No
Reference Name #1
(Required)
First
Last
Telephone Number
(Required)
Company
(Required)
Relationship
(Required)
Number of Years Known
(Required)
Reference Name #2
(Required)
First
Last
Telephone Number
(Required)
Company
(Required)
Relationship
(Required)
Number of Years Known
(Required)
Agreement and Understanding
I understand that this application remains current for sixty (60) days.
(Required)
I certify that my availability to work is as I have stated upon this application. Any variation in this availability prior to hire, upon hire or during the course of employment with LSHS will impact my eligibility for employment or continued employment. I am responsible to accurately provide my work availability on this application, during any process and if I am employed.
(Required)
I hereby certify, under penalty or perjury, that I have not knowingly withheld information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
(Required)
I hereby authorize the Agency to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Agency any and all letters, reports and other information related to my work records. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
(Required)
I understand that to be considered for employment I must provide proof of a current physical and required TB screening. The current physical must state that I am free from communicable disease. I am responsible for the cost of this pre-employment physical and required TB screening. I understand that if I am employed by LSHS the renewal of said physical and required TB screening is at my cost and must be done on an annual or bi-annual basis as dictated by program regulations.
(Required)
I acknowledge that I have read all of the above statements and that I understand them. In addition, the statements above supersede and replace any prior understandings or agreements that I have had with the LSHS. I further acknowledge that I have read and understand all parts of this application. I agree that if I am employed by LSHS, I will abide by all rules, regulations, policies and procedures set forth by LSHS.*
Before Submitting, please download the
physical form
and take it to your primary doctor or nurse for completion. You can bring the completed copy to our office for your interview. Also use this link
Click Here for PA Child Abuse
to apply to for your child Abuse Clearance with the State of Pennslyvina. If you already have unexpired PA Child Abuse Clearance, you can upload it or bring along to your interview.
Date:
(Required)
MM slash DD slash YYYY
If you would like, please fell free to upload a copy of your up-to-date resume for review.
Max. file size: 32 MB.
