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        Personal Information

        Proof of U.S. citizenship or INS Employment Authorization will be required upon employment.

        Date:
        * First Name:
        * Last Name:
        Middle Initial:
        * Address:
        * City:
        * State:
        * Zip:
        * Daytime Phone:
        * Email Address:
        * #1 Job Applying For:
        #2 Job Applying For:
        #3 Job Applying For:
        * Which job status is most desirable to you (check all that apply) Full-Time Part-Time PRN
        * Which shift is most desirable to you (check all that apply)? Day Evening Night Weekends
        Minimum Salary Desired:
        Criminal History: Have you ever been convicted of a crime? Yes No
        If you have been convicted of a crime, was it a misdemeanor or felony? None Felony Misdemeanor
        Do you have a valid drivers license? Yes No
        Drivers License #:
        Drivers License State:
        Any history of traffic accidents or violations? Yes No
        If so, when?
        When will you be available to begin work? (ex. MM/DD/YY)
        Do you have any relatives employed by Life Centers of Kansas ? Yes No
        If yes, give name and relationship:
        How did you find out about this position?
        If you were referred by a current employee, enter their name:
        * Have you ever been employed by Life Centers of Kansas? Yes No
        If yes, when?
        * Life Centers of Kansas may require you to work a schedule or area other than that for which you may be initially hired. In addition, Life Centers of Kansas requires that you be at work when scheduled and work your entire shift. Will you be able to meet these requirements? Yes No

        Work History


        1. Current/Most Recent Employer
        Name of Company:
        May we contact this employer? Yes No Later
        Phone Number:
        Other Name(s) Used:
        Job Title:
        Address:
        City, State, Zip:
        Did you quit or were you terminated? (yes/no, specify which)
        Current Salary:
        Dates Employed: From To (ex: MM/YYYY)
        Supervisor's Name:
        Reason For Leaving:
        Job Duties/Responsibilities:
        2. Next Previous Employer
        Name of Company:
        May we contact this employer? Yes No Later
        Phone Number:
        Other Name(s) Used:
        Job Title:
        Address:
        City, State, Zip:
        Did you quit or were you terminated? (yes/no, specify which)
        Current Salary:
        Dates Employed: From To (ex: MM/YYYY)
        Supervisor's Name:
        Reason For Leaving:
        Job Duties/Responsibilities:
        3. Next Previous Employer
        Name of Company:
        May we contact this employer? Yes No Later
        Phone Number:
        Other Name(s) Used:
        Job Title:
        Address:
        City, State, Zip:
        Did you quit or were you terminated? (yes/no, specify which)
        Current Salary:
        Dates Employed: From To (ex: MM/YYYY)
        Supervisor's Name:
        Reason For Leaving:
        Job Duties/Responsibilities:
        4. Next Previous Employer
        Name of Company:
        May we contact this employer? Yes No Later
        Phone Number:
        Other Name(s) Used:
        Job Title:
        Address:
        City, State, Zip:
        Did you quit or were you terminated? (yes/no, specify which)
        Current Salary:
        Dates Employed: From To (ex: MM/YYYY)
        Supervisor's Name:
        Reason For Leaving:
        Job Duties/Responsibilities:

        Education


        High School
        Name and Location:
        College
        Name and Location: Major:
        Did you Graduate? Yes No
        Degree/Certificate:

        Professional Credentials / Skills


        Please list all of your skills:
        License/Certification/Registration:
        State/License Number:
        Mo./Yr. Issues:
        Expiration Date:
        Are there any restrictions against your license or registration? Yes No
        If yes, please explain:

        References

        Please list three professional references who are not related to you and who can provide a reference, in addition to your employer(s) reference.

        Reference #1:
        Name: Email Address:
        Phone Number:
        Reference #2:
        Name: Email Address:
        Phone Number:
        Reference #3:
        Name: Email Address:
        Phone Number:

        Resume


        Cover Letter and/or Text Resume:
        Only .txt, .rtf, .pdf, and .doc files will be accepted.
        Attach Resume - OPTIONAL:

        EEOC Compliance


        This company is dedicated equal opportunity in employment without regard to race, religion, gender, sexual orientation, national origin, age, veteran or disabled status, or any other protected class. Reasonable accommodation will be made as appropriate to enable any employee or applicant for employment to safely and properly perform the job applied for as requested and as appropriate.

        The following information is necessary for this company to evaluate its hiring practices and to track its progress and effectiveness in complying with its Affirmative Action Plan and equal employment policies. The information is voluntary and will be kept confidential insofar as possible. Information provided will not be negatively considered in any part of the selection process.

        PLEASE CHECK THE APPROPRIATE BOXES AND COMPLETE THE FOLLOWING ENTRIES
        Sex: Male Female
        Ethnicity:
        Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
        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.
        Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
        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.
        White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North 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.
        Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
        I choose not to provide race and/or gender information at this time.

        Read and Sign


        Life Centers of Kansas is an equal opportunity employer. We do not discriminate on the basis of race, color, age, sex, religion, creed, national origin, marital status, veteran status, disability, or any other legally protected status.

        APPLICANT CERTIFICAION AND RELEASE AUTHORIZATION
        I hereby certify that all information provided on or in connection with this application and attachments thereto is true and complete to the best of my knowledge and I have not knowingly withheld any fact or circumstance. By signature below, I authorize the representative of Life Centers of Kansas to contact all employers I have released for contact in order to provide applicable information to the position sought. I authorize any and all persons contacted by Life Centers of Kansas to disclose fully all information available to such persons, whether on record or not, which may have bearing on my application or my employment.

        I understand that if employed, any misrepresentation of the facts as stated or implied on this application form is sufficient cause for dismissal. This application does not bind me or Life Centers of Kansas for any period of employment and I understand that nothing in this application creates any contractual obligation of any kind for either party. If employed, I agree to comply with company policies, procedures and regulations of Life Centers of Kansas and applicable local, state and federal laws as currently exist or may exist in the future.

        My signature to this Application for Employment, provided digitally by typing my full name, certifies that the information I have provided is true and complete. I hereby authorize Life Centers of Kansas to obtain information regarding my former employment, whether educational, criminal or other personal records by reading and agreeing to the disclosure statements herein.
        * Check here to confirm your agreement:
        * Type your full name:
        * Type today’s date: