Life Centers of Kansas Job Application 

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

  • Press the Submit Application button when you have completed your application.  

     * Indicates Required Fields

Personal Information

Job Details

Work History

1. Current/Most Recent Employer

2. Next Previous Employer

3. Next Previous Employer


Professional Credentials / Skills


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:

Reference #2:

Reference #3:

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.

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.

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.

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