LifePath, Inc.
Application for Employment

Lehigh Valley Office: 3500 High Point Boulevard, Bethlehem, PA 18017 610-264-5724
Bucks/Montgomery Office: 2 Life Mark Drive, Sellersville, PA 18960 215-257-0471
Delaware County Office: 600 N. Jackson Street, Media, PA 19063 610-566-5029

LifePath is an equal opportunity employer. We recruit, hire, train, and promote without regard to race, color, religion, sex, national origin, age, marital status, veteran status, limited English profiency or handicap.

Personal Information:

Name:
(Last) (First) (Middle Initial)

Have you ever been known by another name? If yes, please list:

 Date of application:

Example: 12/06/2007
Address:
(No., Street) (City) (State) (Zip)
Telephone Number:

Example: 610-555-1234
Permanent Address: (if different from above)
(No., Street) (City) (State) (Zip)
Alternate Phone Number:

Example: 610-555-1234
Social Security Number: (LifePath cannot guarantee the privacy of your SSN sent via this internet form. If you choose not to include it, please be aware that a SSN will be required at the next stage of the application process.)
- -
Example: 555-55-5555

Are you 18 or older? Yes No

If hired, can you furnish proof that you are legally entitled to work in the U.S.?
Yes No


Have you ever been convicted of a crime: Yes No

If yes, please explain below, giving date, charge dispositions and other details you feel are applicable:

(Please note that a conviction itself is not an automatic bar to employment. Factors such as how the conviction relates to fitness to perform the job in question will be considered.)

Have you ever been fired for abuse or neglect: Yes No

If yes, explain:

Have you ever been employed by LifePath (A.K.A. Community Foundation):
Yes No

If yes, give details:

List any relatives who are currently employed by LifePath:
(Name and Relationship)


How were you referred to LifePath? (Please select one)
Own accord
Employee referral (name of employee):
Newspaper/Internet Ad (please indicate which one):
Other (please list):


Position applying for:

Date available for work:

Example: 12/06/2007

Type of employment desired: Full-time Part-time Fill-In

Hours available to work: (select all preferences)
Days
Evenings
Nights
Weekends
Holidays
Any Shift
Temporary
Summer Only


Education:

High School: (Name, City and State)
 Did you receive a
High School Diploma
G.E.D.
College or Other Schools Attended: (Name)
 Location:
(City, State)
 Did you graduate?
Yes
No 		Degree:
 Curriculum:

Employment History: (List Present Position First)
*Must include name and address of all human service agencies with whom you have previously been employed.

Present & Former Employers Dates Salary Position & Duties Reason for leaving
Company Name:
 From:

Example: 12/06/2007 		Starting:
Address:

City/State:
 To:

Example: 12/06/2007		 Ending:
Supervisor's Name:

Phone:

Example: 610-555-1234
Present & Former Employers Dates Salary Position & Duties Reason for leaving
Company Name:
 From:

Example: 12/06/2007 		Starting:
Address:

City/State:
 To:

Example: 12/06/2007		 Ending:
Supervisor's Name:

Phone:

Example: 610-555-1234
Present & Former Employers Dates Salary Position & Duties Reason for leaving
Company Name:
 From:

Example: 12/06/2007 		Starting:
Address:

City/State:
 To:

Example: 12/06/2007		 Ending:
Supervisor's Name:

Phone:

Example: 610-555-1234

Which former employers may we contact?

Indicate your professional license, registration, or certification number and type:

From which state: Expiration date: Example: 12/06/2007


Job Skills/Special Training:
Please list any human services, technical, trade, office skills, and special training:


Professional Activities/Academic Achievements:
List membership in any Professional Associations (indicate extent of your participation, including any offices which you held and/or Academic honors you have received and the institutions which granted them to you).

U.S. Military Service:
Are you a veteran of the Armed Services: Yes No

If yes, what type of training or education did you receive while in the military?


Vehicle Drivers Information:
Do you currently possess a valid driver's license: Yes No

(Checking "No" is not necessarily a bar to employment. Not all LifePath positions require driving.)


References:
Include two work-related references not related to you, whom you have known at least one year.

Name Address (City/State) Employer Phone Number Years Known

Example:
610-555-1234

Example:
610-555-1234


I hereby give LifePath the right to make a thorough investigation into my previous employment, education, references and all statements made by me in connection with my application for employment, credit and criminal records check, and any other information relative to my employment; and I release from all liability all persons, companies, and corporations supplying such information.

I understand that any false answer, statement or representation made by me in this application shall constitute cause for denial of employment or discharge. I also understand that nothing contained in this employment application or the granting of an interview is intended to create a contract between LifePath and myself for either employment or for the granting of benefits. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon LifePath unless made in writing. If an employment relationship is established, I understand and agree that it is not for a definite period of time and that I have the right to terminate my employment at any time and that LifePath retains a similar right.

I understand that any offer of employment is conditioned upon my successful completion of a criminal background check, employee physical/TB/chest x-ray and a driver's license check when applicable.

I understand that, if accepted for employment, I will be required to abide by the rules and policies of LifePath and that I willl be on three (3) months orientation for full-time or six (6) months for part-time before being considered a regular employee.

I accept and understand the above terms and conditions. Acceptance is required to submit application.


Criminal History Background Check
Consent Statement

I understand that a check of my Criminal History Background will be conducted by LifePath, Inc. Based upon the program in which I have applied, this investigation may include one or more of the following:

PA State Police Criminal Record Check
PA Child Abuse History Clearance
FBI Criminal Background Check

I understand that if I am hired, I must cease working should a satisfactory Child Abuse Clearance Report not arrive by the 30th calendar day of employment.

If I am found to have a conviction for one or more of the prohibitive offenses, I will not be hired or will be dismissed.

I accept and understand the above consent statement. Acceptance is required to submit application.

Per Act 169 of 1996 as amended by Act 13 of 1997, effective 7/10/98.