Today's Date (required)

Contact Information

First Name (required)

Middle Name

Last Name (required)

Your Email (required)

Home Phone (required)

Cell or Work Telephone Number

Home Address

Personal Information

Were you referred by anyone?
YesNo

If yes, list name and tittle:

Have you ever been employed by Options or Christole?
YesNo

If yes, list title and dates:

Do you know anyone who works at LifeDesigns?
YesNo

If yes, list name and title:

How did you hear about LifeDesigns?

Why do you want to work at LifeDesigns Inc?

Are you at least 18 years of age? (required)
yesno

Do you have a valid driver’s license in the State of Indiana and a clean driving record? (required)
Many of our positions require the ability to drive for the agency.
YesNo

LifeDesigns is required by regulating authorities to obtain criminal background checks on all employees

Do you have a legal right to work in the United States? (required)
(LifeDesigns will use to E-verify your status)
YesNo

Education

Do you have the minimum of a high school diploma or GED certification? (required)
YesNo

Select your Highest Level of Education:
---High School DiplomaPost Secondary DegreeGraduate Degree

High School

Name:

City/State:

Did you graduate?
YesNo

Post Secondary Education 1

Name:

City/State:

Major/degree:

Did you graduate?
YesNo

Post Secondary Education 2

Name:

City/State:

Major/degree:

Did you graduate?
YesNo

Position & Availability

What position are you interested in interviewing for?

Anticipated rate of pay:

Are you looking for full time of part time?
Part TimeFull TimeEither

When are you available to start work on?

Many of the facilities of LifeDesigns operate 24 hours a day, 365 day a year.
What is your availability? Please list available hours/days:

Employment History

Are you currently employed?
YesNo

If yes, please list current employer name, phone and address.

May we contact your current employer?
YesNo

Past Employment History

JOB 1

Company Name:

City/State:

Job Title/Job duties:

Dates of employment:

Why did you leave?

May we contact?
YesNo

JOB 2

Company Name:

City/State:

Job Title/Job duties:

Dates of employment:

Why did you leave?

May we contact?
YesNo

JOB 3

Company Name:

City/State:

Job Title/Job duties:

Dates of employment:

Why did you leave?

May we contact?
YesNo

Additional Information

Any additional comments:

You will be required to complete a paper application prior to interviewing with LifeDesigns.

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