EMPLOYMENT APPLICATION
Lakeshore Regional Entity (hereinafter known as LRE) is an Equal Opportunity Employer. Race, color, religion, age, sex, disability, marital or veteran status, place of national origin and other categories protected by law are not factors in employment, promotion, compensation or working conditions.APPLICANT INFORMATION
Full Legal Name:Address:
City: / State: / Zip Code:
Telephone #:
Cell Phone #: / E-mail Address:
My cover letter: is attached has already been sent will be sent separately
My resume: is attached has already been sent will be sent separately
(NOTE: Your application will not be considered until all required documentation is provided.)
Have you ever applied to, volunteered with, or worked for LRE before? Yes No
If yes, when?
Is any additional information relative to a different name necessary to check your work record? Yes No
If yes, please list any prior names used in the course of employment:
For which position are you applying?
How did you hear about LRE or this position?
Do you have any relatives already employed by LRE? Yes No
If yes, please list their name(s) and their relation to you:
If hired, can you provide proof that you are at least 18 years of age? Yes No
If hired, can you provide proof of your employment eligibility? Yes No
(Proof of U.S. Citizenship or immigration status will be required for employment.)
Do you have a valid driver's license? Yes No
Are you able to perform the essential duties of the job as described in the attached job description with or without accommodation?
Yes – No accommodations are required.
Yes – Accommodations will be needed. Please describe:
No – I am unable to perform the essential duties of the job and no accommodation is available to assist me in doing so.
Have you ever been convicted of a crime? Yes No
If yes, explain in full. If you need additional space, please attach a separate page and make note of the attachment here.
Do you have any criminal charges currently pending against you? Yes No
If yes, explain in full. If you need additional space, please attach a separate page and make note of the attachment here.
(NOTE: No applicant will be denied employment solely on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
If hired, on what date could you start work?
Hourly rate of pay or annual salary desired?
Do you have any other commitments to another employer that may affect your employment at LRE? Yes No
If yes, please explain:
MILITARY SERVICE RECORD
Did you serve in the Armed Forces? Yes No
If yes, in which branch?
Dates of Service: From: To:
Rank at Separation:
Type of Discharge: Honorable Dishonorable
Special training received:
LICENSES, CERTIFICATIONS & SPECIAL SKILLS
Type of License / Identification # / Expiration Date / Issued By:Certifications / Identification # / Expiration Date / Issued By:
Do you have any other experience, training, qualifications or skills that you feel make you especially suited for work at LRE?
Yes No
If yes, please explain in detail:
Professional Society Memberships:
(Please exclude organizations that indicate race, color, religion, gender, national origin, disabilities or other protected status.)
Do you fluently speak, read, write or understand any foreign languages? Yes No
If yes, which language(s)?
EDUCATIONAL EXPERIENCE
Type of School Educational Experience / Name & Address
Of School / Course of Study / # of Years
Completed / Diploma/
Degree
High School
Undergraduate
Graduate
Vocational or Other
COMPUTER SKILLS
LRE utilizes a number of electronic business systems and is steadily moving toward a paper-free environment, as such staff members are required to be skilled in the use of computer systems and software packages. As part of the candidate screening process, these skills will be evaluated. Please describe your level of proficiency in the space below.
Computer Knowledge / Level of Proficiency
(Basic, Intermediate, Advanced)
Hardware:
Software:
EMPLOYMENT HISTORY
List all previous employers starting with your present or most recent below. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities or other protected status. All of the requested information must be provided.
Name of Company:
Name of Supervisor:
Address:
Street / City / State / Zip Code
Telephone Number:
Position and Duties:
Employment Dates:
Reason for Leaving:
Name of Company:
Name of Supervisor:
Address:
Street / City / State / Zip Code
Telephone Number:
Position and Duties:
Employment Dates:
Reason for Leaving:
Name of Company:
Name of Supervisor:
Address:
Street / City / State / Zip Code
Telephone Number:
Position and Duties:
Employment Dates:
Reason for Leaving:
Name of Company:
Name of Supervisor:
Address:
Street / City / State / Zip Code
Telephone Number:
Position and Duties:
Employment Dates:
Reason for Leaving:
REFERENCES
Please provide a minimum of four professional / employment references (of these, at least two must be from former supervisors; one or two from peers or co-workers, and one from a subordinate or person you supervised, if applicable). Please note that all employers, schools, and volunteer settings may be contacted for reference and background checking.Name of Contact, Title, and Relationship to your Position / Business Name & Address / Area Code & Telephone Number
Please read each of the following paragraphs carefully and initial them in the space provided to the left of each one.
I verify that the information given by me in this application is true, correct, and complete. I understand that if I have given any false information on the application or if I have omitted any material facts, I may be disqualified from employment with LRE, or if hired, I may be discharged immediately upon discovery of such false statements or omissions, regardless of the time elapsed before discovery.
I hereby authorize my current and former employers to release any information contained in my personnel file or otherwise known by them to LRE in connection with my application for employment with LRE. I specifically release from liability any current or former employers, their agents, representatives, employees, officers or directors, for giving such information to LRE.
I agree that any claim or lawsuit related to my service with LRE must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.
I understand that, if hired, my employment is at-will unless my position is included in the bargaining unit of LRE, meaning that either the employer or I may terminate the employment relationship at any time with or without notice and with or without cause. This provision supersedes any oral or written representations to the contrary, unless the Executive Director of LRE signs a written statement.
My signature below certifies that I have read and understand this complete page, and agree to the terms and conditions outlined in this document.
Applicant's SignatureDate