LIFEPATH, INC.
APPLICATION FOR EMPLOYMENT

Lehigh Valley Office: 3500 High Point Boulevard, Bethlehem, PA 18017610-264-5724
Bucks/Montgomery Office: 2 Life Mark Drive, Sellersville, PA 18960215-257-0471
Delaware County Office: 600 N. Jackson Street, Media, PA 19063610-566-5029

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.

NAME:
First: Middle: Last:
(First Name is required)(Last Name is required)

ADDRESS:
Street: City: State: Zip:
(Street is required) (City is required) (State is required) (Zipcode is required)

TELEPHONE #:     ALTERNATE PHONE #:
(Primary Phone # format 123-123-1234 is required) (Alternate Phone # format 123-123-1234 is required)

SOCIAL SECURITY #:
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.

HAVE YOU EVER WORKED USING ANOTHER NAME? Yes      No
(You must select "Yes" or "No" for the question)
If Yes, please list:

Are you 18 or older? Yes      No
(You must select "Yes" or "No" for the question)

If hired, can you furnish proof that you are legally entitled to work in the United States? Yes      No
(You must select "Yes" or "No" for the question)

Have you ever been convicted of a crime, other than a minor traffic violation? Yes      No
(You must select "Yes" or "No" for the question)
If Yes, please explain below giving date, charge, 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, along with any regulatory requirements and date of conviction)

Have you ever been fired for abuse and/or neglect? Yes      No
(You must select "Yes" or "No" for the question)
If Yes, please explain:

Have you ever been employed by LifePath (fka – Community Foundation for Human Development)? Yes      No
(You must select "Yes" or "No" for the question)
If Yes, please give date, position held and reason for separation:

List any relatives who are currently employed at LifePath:
(All relatives employed by LifePath are required to be listed)
Name: Relationship:      Name: Relationship:

How were you referred to LifePath?
(You must select an referred option)
Own Accord
Employee Referral (Please give name of employee)
Newspaper (Please list name of newspaper/publication)
Internet (Please list name of site)
Other (Please explain)

Position Applying For:
(Please give the position you are applying for)

Date Available for Work:
(Correctly formatted date is required)
//

Type of Employment desired: Full-Time  Part-Time  Fill-In  Summer
(Please select employment options)

Please List Days and Hours Available for Work:
  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
From
To
Please list any other additional availability information:

EDUCATION/JOB SKILLS/SPECIAL TRAINING/PROFESSIONAL ACTIVITIES/ACACEMIC ACHIEVEMENTS:
(name/location of highschool) (course of study) (years completed) (received diploma)
  Name & Location of School Course of Study Number of
Years Completed		 Diploma, GED or
Degree Received
High School
College
Vocational or Trade School
Graduate Work

Indicate your professional license, registration, or certification number and type
(please do not include Driver’s License information):

From Which State:
Expiration Date: //

Do you belong to any professional, trade, business or civic organizations that deal with the position for which you are applying? Yes      No
(You must select "Yes" or "No" for the question)
If Yes, please explain (Omit any organization which reflects your race, color, religion, sex, national origin, age, marital status, veteran status, limited English proficiency or disability).

Please list any academic honors you have received and the school/colleges which granted them to you:

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)
(You must select "Yes" or "No" for the question)

Do you have a clean three (3) year driving record? Yes      No
(You must select "Yes" or "No" for the question)
If No, please explain:

EMPLOYMENT HISTORY (Please start with your most recent position. If you have worked for any other human service agencies, you must include that information):

Name of Employer:   Supervisor's Name and Title:
Address:
Telephone #:
Dates of Employment: From: //    To: //
Starting Salary: $ /hour   Ending Salary: $ /hour
Briefly describe job responsibilities:
Reason for Leaving:

Name of Employer:   Supervisor's Name and Title:
Address:
Telephone #:
Dates of Employment: From: //    To: //
Starting Salary: $ /hour   Ending Salary: $ /hour
Briefly describe job responsibilities:
Reason for Leaving:

Name of Employer:   Supervisor's Name and Title:
Address:
Telephone #:
Dates of Employment: From: //    To: //
Starting Salary: $ /hour   Ending Salary: $ /hour
Briefly describe job responsibilities:
Reason for Leaving:

Name of Employer:   Supervisor's Name and Title:
Address:
Telephone #:
Dates of Employment: From: //    To: //
Starting Salary: $ /hour   Ending Salary: $ /hour
Briefly describe job responsibilities:
Reason for Leaving:

REFERENCES (please include two work related references not supervisors or relatives, whom you have known at least one year):
NAME ADDRESS
(City and State)		 EMPLOYED
BY		 PHONE
NUMBER		 YEARS
KNOWN
^required ^required ^required ^required ^required
^required ^required ^required ^required ^required

AUTHORIZATION AND CRIMINAL HISTORY BACKGROUND CHECK CONSENT

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 will be on three (3) months orientation for full-time or six (6) months for part-time before being considered a regular employee.

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.

I understand that if I am hired, I must cease working should a satisfactory FBI Criminal Background Check not arrive by the 90th calendar day of employment.

If I am found to have a conviction for one or more of the prohibitive offenses as outlined by both LifePath policy and regulations, I will not be hired or will be dismissed.

 I understand and agree to the above terms and consent
You must agree to the terms