Employment Application

Step 1 of 12 - General Information

General Information

Position Applying For:(Required)

Application Date:(Required)

Name:(Required)

First Middle Last

Your Pronouns(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone:(Required)

Email:

List any other name(s) you have been known by:

Have you ever been employed here before?(Required)

Yes

What previous position did you hold?(Required)

When did you previously work for us?(Required)

Are you legally eligible for employment in this country?(Required)

Yes

Have you ever tested positive, or refused a test, on any pre-employment drug or alcohol test administered by an employer?(Required)

Yes

When would you be available to start?(Required)

Type of Employment Desired:(Required)

Full-Time

Part-Time

Substitute

How did you learn about this position?(Required)

Please share the name of the employee who referred you.(Required)

Will you accept employment anywhere in the twelve counties we serve?(Required)

Yes

Which counties do you prefer?(Required)

Blackford County

Delaware County

Grant County

Henry County

Jay County

Madison County

Randolph County

Education Record

Did you graduate from high school or obtain a G.E.D.?(Required)

Yes

High School Name:(Required)

City & State:

Did you graduate from Trade, Business, or Vocation School?

Yes

School Name:(Required)

City & State:

Field of Study:

College & Universities

Name

Location

Grade Avg.

Total Hrs.

Major

Degree

Graduation Date

College & Universities (Additional entries, if applicable)

Name

Location

Grade Avg.

Total Hrs.

Major

Degree

Graduation Date

What office equipment can you operate efficiently?

Have you had training or experience with computers?

Yes

Please list the software with which you are proficient:

Please list other qualifications you possess which you want considered:

Employment Record

Would you like to upload a cover letter?

Yes

Cover Letter Upload

Max. file size: 800 MB.

Would you like to upload a resume?

Yes

Resume Upload

Max. file size: 800 MB.

May we contact your present employer?(Required)

Yes

Your current or most recent employer:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Position Held:(Required)

Start Date:(Required)

End Date:

Leave blank if this is your current employer.

Current or Ending Pay:(Required)

Describe Your Duties & Responsibilities:(Required)

Supervisor's Name:(Required)

Phone:(Required)

Employment Record

Would you like to add another employer?(Required)

Yes

Employer #2:

Address:

Street Address Address Line 2 City State ZIP Code

Position Held:

Start Date:

End Date:

Ending Pay:

Describe Your Duties & Responsibilities:

Supervisor's Name:

Phone:

Employment Record

Would you like to add another employer?(Required)

Yes

Employer #3:

Address:

Street Address Address Line 2 City State ZIP Code

Position Held:

Start Date:

End Date:

Ending Pay:

Describe Your Duties & Responsibilities:

Supervisor's Name:

Phone:

Employment Record

Have you been discharged or involuntarily resigned from any position in the last five years?(Required)

Yes

Please list the employer and explain:(Required)

Professional References

List at least three (3) persons who are familiar with your work qualifications and character.(Required)

Name

Phone

Relationship

Application Certification & Conditions of Employment

By checking each box, you acknowledge that you have read each statement and agree to these statements:(Required)

I hereby certify that all information made on or in connection with this application is true and complete to the best of my knowledge and I have not knowingly withheld any fact or circumstance. I understand that if any of the statements made by me on this application are false it will be sufficient grounds for rejection of my application or removal from employment. I further understand some positions are contingent on results from drug testing and a medical examination for job fitness.

I understand LifeStream Services, Inc. participates in the federal E-Verify program. I understand through this program LifeStream Services, Inc. will provide the Social Security Administration and, if necessary, the Department of Homeland Security, with information from each new employee’s Form I-9 to confirm work authorization.

By authorizing the above, I agree to hold harmless any individual, partnership, corporation, educational institution or agency, its officers, agents, and employees from any liability for any damage whatsoever for issuing such information.

Please initial (this will be used as your signature)(Required)

Background Check Authorization

Background Check Authorization(Required)

By checking each box, you acknowledge that you have read each statement and agree to these statements:

I hereby authorize LifeStream Services, Inc. and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment processes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to LifeStream Services, Inc. or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I further authorize LifeStream Services, Inc. to do an annual and/or random background checks for the purpose of evaluating my continued employment.

I understand pursuant to the federal Fair Credit Reporting Act, LifeStream Services, Inc. will provide me a copy of any such report if the information contained in it is, in any way, to be used in making a decision regarding my employment and/or continued employment with LifeStream Services, Inc. I further understand that such report will be made available to me prior to any such decision being made.

I hereby release LifeStream Services, Inc., and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

Please initial (this will be used as your signature)(Required)

Request for Reference

Reference Authorization(Required)

By checking the box below, you acknowledge that you have read and agree to the statement:

I authorize LifeStream Services, Inc. to contact my current and any former employers and references in order to investigate my past performance and other information contained on my application. I further authorize my current and former employers to respond to the questions set forth by LifeStream Services, Inc. and its designated representatives.

Please initial (this will be used as your signature)(Required)

Voluntary Equal Employment Opportunity (EEO) Self-Identification Form

Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, or other protected characteristic.

The employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.

The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Name

First Middle Last

Address

Street Address Address Line 2 City State ZIP Code

Position Applied For:

Date of Application:

Gender Identification:

Female

Male

Race/Ethnic Identification:

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Decline self-identification

Please initial (this will be used as your signature)(Required)

Voluntary Self-Identification of Disability

Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017

Please check one of the boxes below:(Required)
Yes, I have a disability (or previously had a disability)
No, I do not have a disability
I do not wish to answer

Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
Autism
Bipolar Disorder
Blindness
Cancer
Cerebral Palsy
Deafness
Diabetes
Epilepsy
Autism
HIV/AIDS
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)
Major depression
Missing limbs or partially missing limbs
MS
Muscular dystrophy
Obsessive compulsive disorder
Post-traumatic stress disorder
Schizophrenia

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Voluntary Self-Identification of Protected Veteran

If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1975, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work and duties of disabled veterans, and regarding necessary accommodations; (ii) safety committee members may be informed, when and to the extent appropriate, if you have condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

If you believe you belong to any of the categories of protected veterans listed below, please indicate by checking the appropriate box.
I identify as one or more of the classifications of protected veteran listed above
I am not a protected veteran
I prefer not to answer

LifeStream Services, Inc. is subject to the Vietnam Era Veteran’s Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires LifeStream to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

Disabled veteran – a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

Recently separated veteran – any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.

Active duty wartime or campaign badge veteran – any veteran who served on active duty in the U.S. military, ground, naval or air services during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

Armed Forces service medal veteran – any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA – the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

As an employer subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

As an employer subject to VEVRAA, we are required to submit a report to the United States Department of Labor annually identifying the number of employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box.
I belong to a protected veterans category
I am a protected veteran, but I choose not to self-identify the classification to which I belong
Armed Forces service medal veteran

Choose Protected Veteran Category:
Disabled Veteran
Recently Separated Veteran
Active Wartime or Campaign Badge Veteran
Armed Forces Service Medal Veteran

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REFERRAL

Employment Application

General Information

Education Record

Employment Record

Employment Record

Employment Record

Employment Record

Professional References

Application Certification & Conditions of Employment

Background Check Authorization

Request for Reference

Voluntary Equal Employment Opportunity (EEO) Self-Identification Form

Voluntary Self-Identification of Disability

Reasonable Accommodation Notice

Voluntary Self-Identification of Protected Veteran

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