VIEW OUR NEWSLETTER DONATE NOW 202-966-6667 ONLINE EMPLOYMENT APPLICATION It is the policy of the Home to provide an equal employment opportunity to all qualified employees and qualified applicants for employment without regard to race, color, religion, sex, national origin, sexual orientation, age, or disability, or any other basis prohibited by law. This policy applies to all terms and conditions of employment including, but not limited to, hiring, placement, training, compensation, transfer, promotion, leave of absence, termination, layoff and recall. PERSONAL INFORMATION: Last Name First Name MI Date of Application Current Street Address City, State, Zip, Code Home Telephone Business Telephone Have you ever applied for employment with us? Yes No If yes, when? Position Have you ever worked here before? Yes No If yes, when? Position Position Applying for: Date You Can Start Are you a citizen of the United States? Yes No If no, are you legally eligible to work in the United States? Select Options (IF YOU ARE NOT A UNITED STATES CITIZEN AND YOU ARE NOT LEGALLY ELIGIBLE TO WORK IN THE UNITED STATES, YOU CANNOT BE EMPLOYED AT THE LISNER-LOUISE-DICKSON-HURT HOME.) Please provide any professional license or certification numbers if applicable to the position for which you are applying License or Certification Number Issued By Whom? First Name Last Name Place of Issuance Date of Last Renewal Has your license or certification ever been suspended or revoked by any state? Yes No The Home operates on a 7 days-a-week, 24 hours-a-day schedule. It may be necessary for you to work any shift as well as weekends and holidays. Are you available to meet these requirements, as needed? Yes No If no, please explain Please indicate below in your order of preference, with “1” being your first choice and “3” being your last choice, which shift(s) you prefer to work: Day Shift (7:00 a.m. – 3:30 p.m.) Evening Shift (3:00 p.m. – 11:30 p.m.) Night Shift (11:00 p.m. – 7:30 a.m.) Are you available for full-time employment? Yes No Are you available for part-time employment? Yes No Are you available for temporary or seasonal (summer only) employment? Yes No Are you available for on-call employment? Yes No EDUCATION School Name and Location Course of Study Yrs. Completed Degree or Diploma Graduate College High School EMPLOYMENT HISTORY Please give an accurate and complete employment history. Be sure to include any relevant volunteer experience you may have had. Start with your current or most recent employer. 1. Company Name Telephone Address City State Employed (State month and year) From To Name of Immediate Supervisor Salary or Wages Paid Beginning Ending Job Title/Description of Duties Reason for Leaving 2. Company Name Telephone Area Code Phone First 3 Phone Last 4 Address City State Zip Code To Name of Immediate Supervisor Salary or Wages Paid Beginning Ending Job Title/Description of Duties Reason for Leaving 3. Company Name Telephone Address City State Zip Code Employed (State month and year) From To Name of Immediate Supervisor Salary or Wages Paid Beginning Ending Job Title /Description of Duties Reason for Leaving 4. Company Name Address City State Zip Code Telephone Employed (State month and year) From To Name of Immediate Supervisor Salary or Wages Paid Beginning Ending Job Title /Description of Duties Reason for Leaving Select Options We may contact any or all of the employers listed above unless you indicate those you DO NOT want us to contact: Employer/Company Number(s) Reasons Please account for any periods of time during your work history when you were unemployed: Are any of your relatives currently working for us? Yes No If yes, please list their names : Are you over 18 years of age? Yes No If no, can you submit a work permit? Yes No IF YOU CANNOT PRODUCE A VALID WORK PERMIT AND YOU ARE UNDER 18 YEARS OF AGE, YOU CANNOT WORK AT THE LISNER-LOUISE-DICKSON-HURT HOME. Select Options The information provided in this application for employment is true, correct, and completes to the best of my knowledge. If you employ me, I understand that false or misleading information given in my application or interview(s) may result in discharge and that my first 90 days of employment will be probationary, with the possibility of extension at the Home’s discretion. In consideration of my employment, I agree to conform to the rules and regulations of the Lisner-Louise-Dickson-Hurt Home and understand that my employment and compensation can be terminated, with or without cause, and with or without notice at any time, at the option of the Home or myself. I also understand that nothing appearing in the Home’s employee handbook or any other publication changes this “at-will” relationship. Select Options I authorize you to make such investigations and inquires of my personal employment history from my past employers as may be necessary in arriving at an employment decision. I hereby release employers, schools, or other individuals from all liability in responding to inquiries in correction with my application for employment. Signature of Applicant Date NOTE Your application will be considered active for 30 calendar days. After that time, if you continue to have interest in employment with the Lisner-Louise-Dickson-Hurt Home, you may be required to submit another application. SUBMIT 8007 25024