The Life Counseling Center P.A: Paper and Online Application

Application for Employment

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Please complete each section in its entirety. All fields marked with an * are required. After completion please click on the Submit Button Below. Someone from Life Counseling Center will contact you within 5 Business Days.

Name of Applicant *

Mailing Address *

City *

State *

Zip *

Home Phone *

Cell Phone *

E-mail *

By Checking this Box I certify that I am eligible to work in the United States.

Have you ever been convicted of or pleaded no contest to a felony the last five years?:

Yes

If Yes Please Explain

Position Applied For *

Please let us know why you are interested in this position, your qualifications and experience and why you are interested in working at the Life Counseling Center. *

Days and Hours Available: *

What Date are you Available to start work? *

Education Background:

Name and Address of School *

Major, Degree, Diploma *

Graduation Date *

Name and Address of School

Major, Degree, Diploma

Graduation Date

Name and Address of School

Major, Degree, Diploma

Graduation Date

Please list any current Licenses, Awards, Certifications and Trainings that would benefit you in this job. *

Employment History

Present or Last Position

Employer Name: *

Address: *

Supervisor Name: *

Phone: *

Position Title: *

From: *

To: *

Salary: *

Responsibilities: *

Reason For Leaving: *

Previous Position

Employer Name

Address:

Supervisor Name:

Phone:

Position Title:

From:

To:

Salary:

Responsibilities:

Reason For Leaving:

Previous Position:

Employer Name

Address:

Supervisor Name:

Phone:

Position Title:

From:

To:

Salary:

Responsibilities:

Reason For Leaving:

May We Contact Your Present Employer *

References

Name/Title: *

Phone: *

Occupation: *

Relationship to Applicant: *

Name/Title: *

Phone: *

Occupation: *

Relationship to Applicant: *

Name/Title:

Phone:

Occupation:

Relationship to Applicant:

Declaration

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all of the information listed above.

Electronic Signature of Applicant: *

Date: *

( * Required Field )

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