Applicant Information:

Applicant Name*

Street Address*

City/Town*

State*

Zip Code*

Telephone Number*

Email Address*

Employment Position:

Position(s) applying for:

How did you hear about this position?

What days are you available to work?

On what date can you start working?

Personal Information:

Are you 18 years of age or older?
YesNo
Are you a U.S. Citizen or approved to work in the United States?
YesNo
What document can you provide as proof of citizenship or legal status?

Do you have any condition which would require job accomodations?
YesNo
If yes, please describe accomodations required:

Have you ever been convicted of a criminal offense (felony or misdemeanor)?
YesNo
If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.

Job Skills and Qualifications:

Please list the skills and qualifications you possess for the position for which you are applying:

Military Experience:

Branch of Military:

Discharge Date:

How many years served in the military?

What military skills do you possess that would be an asset for the position?

Previous Employment:

Employer Name:

Employer Address:

Employer City/Town

State

Zip Code

Employer Telephone

Job Title:

Supervisor Name:

Dates Employed:
From:
To:
Reason for Leaving

Employer Name:

Employer Address:

Employer City/Town

State

Zip Code

Employer Telephone

Job Title:

Supervisor Name:

Dates Employed:
From:
To:
Reason for Leaving

Employer Name:

Employer Address:

Employer City/Town

State

Zip Code

Employer Telephone

Job Title:

Supervisor Name:

Dates Employed:
From:
To:
Reason for Leaving

Additional Information:

Would you consent to a CORI background check?
YesNo

AT-WILL EMPLOYMENT

The relationship between you and the Lappin Foundation is referred to as “employment-at-will”. This means that your employment can be terminated at any time for any reason, with, or without cause, with or without notice, by you or the Lappin Foundation. No representative of the Lappin Foundation has authority to enter into any agreement contrary to the foregoing “employment-at-will” relationship. You understand that should you be hired, your employment is “at will”, and that you acknowledge that no oral or written statement or representations regarding your employment can alter your at-will-employment status, accept for a written statement signed by you and the Executive Director.

Enter Your Name (Digital Signature):

Date:

By checking this box I confirm the information on this form is true to the best of my knowledge.

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