Life's Potential Services Employment Application Please fill out the form to apply. Step 1 of 15 6% Applicant InformationType of Position Desired(Required) Name(Required) First Middle Initial Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone(Required)Home PhoneEmail(Required) Applicant InformationHave you ever been convicted of a felony or released from prison within the last seven years?(Required) Yes No Note: Records of arrest do not necessarily prevent employment in all positions. Juvenile records are not applicable.Please describe, including dates:(Required)Are you a citizen of the United States?(Required) Yes No Are you authorized to work in the United States? Yes No Name the country you are a citizen: Do you have a valid Maryland driver’s license?(Required) Yes No Can you provide your own transportation for field work if the job requires it?(Required) Yes No HiddenAre you 20 years of age or older? Yes No Have you filed an application here before?(Required) Yes No If so, when? Please choose a date.(Required) MM slash DD slash YYYY Have you been employed here before?(Required) Yes No List a date range when you were employed here: Do any of your relatives work here?(Required) Yes No Do any of your relatives serve as Board member?(Required) Yes No Please list name(s) and relationship(s): High School EducationHigh School HiddenAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Did you graduate high school? Yes No Diploma/Degree: Describe Course Of Study Do you have a college education?(Required) Yes No Do you have any other schooling, certificates or training?(Required) Yes No College EducationCollege/University HiddenAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Did you graduate college? Yes No College Degree: Describe Course Of Study Second College Degree: Describe Course Of Study Do you have any other schooling, certificates or training?(Required) Yes No Other Schooling, Certificates & TrainingOther School/Specialized Training HiddenAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Did you graduate? Yes No Diploma/Degree: Describe Course Of Study License(s) References1st Reference Persons who can attest to your professional capabilities other than supervisors listed above in employment record, excluding relatives.Name First Last Relationship Company PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code References2nd Reference Persons who can attest to your professional capabilities other than supervisors listed above in employment record, excluding relatives.Name First Last Relationship Company PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code References3rd Reference Persons who can attest to your professional capabilities other than supervisors listed above in employment record, excluding relatives.Name First Last Relationship Company PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have previous employment?(Required) Yes No Do you have military experience?(Required) Yes No Previous EmploymentRecent Previous EmploymentRecent Previous Employer PhoneHiddenAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor First Last Job Title ResponsibilitiesDate Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Major Duties Reason for Leaving May we contact your previous supervisor for a reference? Yes No Do you have a second previous employment?(Required) Yes No Do you have military experience?(Required) Yes No 2nd Previous Employment2nd Previous Company PhoneHiddenAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor First Last Job Title ResponsibilitiesDate Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Major Duties Reason for Leaving May we contact your previous supervisor for a reference? Yes No Do you have a third previous employment?(Required) Yes No Do you have military experience?(Required) Yes No 3rd Previous Employment3rd Previous Company PhoneHiddenAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor First Last Job Title ResponsibilitiesDate Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Major Duties Reason for Leaving May we contact your previous supervisor for a reference? Yes No Do you have military experience?(Required) Yes No Military ServiceBranch of Service Date Entered MM slash DD slash YYYY Date Discharged MM slash DD slash YYYY Rank at Discharge Type of Discharge If other than honorable, explain.Are you now a member of a Reserve or National Guard? Yes No Are you still active duty? Yes No Availability & Employment InformationIf offered employment, how soon can you be available for work? (Date Available)(Required) MM slash DD slash YYYY Are you interested in full time or part time employment?(Required) Full Time Part Time I am available the following days(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday Hours Tuesday Hours Wednesday Hours Thursday Hours Friday Hours Saturday Hours Sunday Hours I would like to work approximately this many hours per week:(Required) 10 hours 15 hours 20 hours 25 hours 30 hours 35 hours Check the areas you would like to work Baltimore City Carroll County Howard County NON-DISCRIMINATION NOTICE As an equal opportunity employer, Life Renewal Services, Inc. wishes to be sure that you are aware that jobs are open to all qualified applicants regardless of age, national organ, race, sex or handicap. The following information is required sole for reports to various governmental agencies and in furtherance of our Affirmative Action Efforts. Therefore, you are not required to respond to the items below.Gender Male Female Race White (Non-Hispanic) Black (Non-Hispanic) Hispanic American Indian or Native Alaskan Haitian or Pacific Islander HEALTH NOTICEThe Secretary of Health and Human Services has determined that certain diseases including hepatitis A, salmonella, shigella, staphylococcus, streptococcus, and giardia may prevent you from serving food or handling food equipment in a sanitary or healthy fashion. An essential function of this job may involve handling and serving food, food service equipment and utensils in a sanitary and health fashion. Is there any reason why you cannot perform the essential functions of this job? Yes No If yes, please explain CERTIFICATION 1. I certify that the information contained on this application is correct to the best of my knowledge and understand that any omission or erroneous information is grounds for dismissal in accordance with the policy of Life Renewal Services. 2. I authorize the references listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnished same to you. 3. I acknowledge that Life Renewal Services, Inc. reserves the right to amend or modify the policies in its personnel manual and other policies of Life Renewal Services, Inc. at any time, without prior notice. These policies do not create any promises or contractual obligations between Life Renewal Services and its employees. I understand that my employment at Life Renewal Services, Inc. is at will. This means I am free to terminate my employment at any time, for any reason, with or without cause, and Life Renewal Services retains the same rights. Signature(Required)Typing your name acts as your signature. First Last I do hereby authorize the release of any information and/or review of the full disclosure of all records or any part thereof concerning myself, by and to Life Renewal Services, Inc. or its authorized agents, whether the said records are public, private or of a confidential nature. The intent of this authorization is to give my consent for full and complete disclosures or against me, salary records, records of complainant, arrest, trials, and/or traffic records; records of a civil nature made by or against me, where so located, to include the records and recollections of attorneys at law, or of other counsel whether representing me or another person in any case in which I presently have or have had an interest. It is my specific intent to provide access to personal information, however personal or confidential it may appear to be, and the sources of information specifically enumerated above is not intended to deny access to any records not specifically intended herein. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon release authorization will be considered in determining my suitability for employment by Life Renewal Services, Inc.(Required) I authorize Signature(Required)Typing your name acts as your signature. First Last Date MM slash DD slash YYYY Upload Resume FileAccepted file types: pdf, doc, docx, Max. file size: 3 MB.
