Employment Form

Position(s) for which application is being completed:

Name

Phone

Email Address

Address

City

State

Zip

Are you older than 18?

Yes

If under age 18, date of birth

If under age 18, can you furnish a work permit?

Yes

EDUCATION

Highest grade completed:

High School

High School Name:
High School Location:
Date attended: From To
Graduate:

College

College Name:
College Location:
Date attended: From To
Graduate:

Other

Other Education:
Location:
Date attended: From To
Graduate:

Special Training

Special Training Name:
Location:
Date attended: From To
Graduate:

Related skills to the position(s) for which you are applying?

Are you presently employed?

Yes

When would you be available to begin work if offered a position of employment?

Have you ever been employed by Lutheran Social Ministries?

Yes

If yes, Location / Department

Have you worked in a social ministry before?

Yes

If yes, please supply details

Why are you interested in working for Lutheran Social Ministries?

How did you learn about employment possibilities with Lutheran Social Ministries?

Are you interested in

Part-time

Full-time

Temporary work

Per Diem

If temporary, please explain

Are there any hours when you would not be available for work at Lutheran Social Ministries?

Yes

If yes, please specify.

Are you willing to work weekends?

Yes

Overtime?

Yes

Have you been discharged from any employment other than layoff due to lack of work?

Yes

If yes, give details

Have you been

convicted of any crime?

plead guilty?

no contest?

If yes, please explain

Have you ever been barred or sanctioned by Medicaid or Medicare?

Yes

If yes, give details

Do you use any Illegal Drugs?

Yes

If yes, explain

Please set forth any training or special skills you possess:

MILITARY SERVICE

Did you serve in the U.S. Armed Forces?

yes

No Branch

Date Entered

Date Discharged

PERSONAL REFERENCES (Other than relatives or former employers.)

Name, Occupation, Address, Telephone and Years Known are required. List three

EMPLOYMENT EXPERIENCE Please start with your present or last job. You may include any volunteer activities. You should exclude organizations, which indicate race, color, religion, gender, national origin, sexual orientation, disability or other protected status.

Employer		Position / Job Title
Address		Dates Employed
Phone Number		Hourly Rate / Salary
Supervisor		Reason for Leaving
Work Performed

Employer		Position / Job Title
Address		Dates Employed
Phone Number		Hourly Rate / Salary
Supervisor		Reason for Leaving
Work Performed

Employer		Position / Job Title
Address		Dates Employed
Phone Number		Hourly Rate / Salary
Supervisor		Reason for Leaving
Work Performed

May we contact the employers listed above?

Yes

If not, indicated references and which one(s) you do not wish us to contact

Terms And Conditions
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

DO NOT SUBMIT UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Date

Upload Your Resume:

Mark Biancaniello, SPHR — Corporate Director for Human Resources LSM/NJ 6 Terri Lane, Suite 300 Burlington, NJ 08016

6 Terri Lane, Suite 300 – Burlington, NJ 08016 · phone: 609.386.7171 · fax: 609.386.7191 · email: info@lsmnj.org

An Affiliated Agency of the Lutheran Church-Missouri Synod & The Evangelical Lutheran Church in America