A       L   A   N   D   S   C   A   P   E       &      M   A   I   N   T   E   N   A   N   C   E        C   O.
1388 Longfellow Ave., Suite M.  Chico,  CA  95926   530-894-5433    Fax 530-893-4763     Email

An Equal Opportunity Employer
Employment Application
Please Print
Name                                           Date
Telephone Bus.:                                Cell:                         Home:
Social Security No.
Present Address:

Permanent Address:

Employment Desired:
Position Applying for:
Are you applying for:    Regular or Full-time work
    0 Regular Part-time Work
    0 Temporary Work (summer, or holiday work)
What days and hours are you available to work?
If applying for temporary work during what period of time will you be available? ______________________________________________________________________________________
Are you available on weekends? 0 Yes  0 No
Would you be available to work overtime, if necessary? 0 Yes  0 No
If hired, on what date can you start work? ________________________________________________
Salary desired: ________________________________________________________________________

Personal Information
Have you ever applied to or worked for Lifescapes before? 0 Yes  0 No
If yes, when? __________________________________________________________________________
Do you have any friends or relatives working for Lifescapes? 0 Yes  0 No
If yes, state name and relationship: ______________________________________________________
If hired would you have a reliable means of transportation to and from work? 0 Yes  0 No
Are you at least 18 years old? 0 Yes  0 No
(If you are under 18, hire is subject to verification that you are of the minimum legal age.)
Do you have a current & valid California driverís license? 0 Yes  0 No
If hired can you present evidence of U.S. citizenship or proof of your legal right to live and work in this country? 0 Yes  0 No
Are you able to perform the essential functions of the job for which you are applying?
0 Yes  0 No
If you are not able to perform the essential functions of the job, describe the functions that cannot be performed: _____________________________________________________________________________
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?
0Yes  0No
If yes, state nature of the crime(s), when convicted and disposition of case: ______________________________________________________________________________________
Are you currently employed? 0Yes  0No
May we contact your current employer? 0Yes  0No

Education, Training and Experience
SCHOOL    NAME & ADDRESS    No. of Years    Did you Graduate?    Degree or Diploma
High School
College/ University
Health Care               

Do you speak, write or understand any foreign languages? 0Yes  0No
If yes, which languages? _______________________________________________________________
Do you have any other experience, training, qualifications, or skills which you feel make you especially suited for work at Lifescapes?
If so, please explain: ____________________________________________________________________

Employment History
List below all present and past employment starting with your most recent employer (last 5 years is sufficient). Account for all periods of unemployment.
Name of Employer       
Type Business       
Telephone Number       
Your Position and Duties       
Date of Employment    From:    To:
Weekly Pay    Start:    Ending:
Reason for Leaving       
Name of Employer       
Type Business       
Telephone Number       
Your Position and Duties       
Date of Employment    From:    To:
Weekly Pay    Start:    Ending:
Reason for Leaving       

List below two persons not related to you who have knowledge of your work performance within the last three years.

Name    Occupation    City and Phone #    Years Acquainted

Medical Information
Lifescapes requires that each employee is physically qualified to perform the tasks required by the job. As a condition of employment each employee may be required to take a physical examination as necessary for the safety and welfare of the employee or fellow employees.

Do you have any disabilities? 0Yes  0No
If yes, explain__________________________________________________________________________

Have you ever been compensated for a work-related injury? 0Yes  0No
If yes, explain__________________________________________________________________________
Lifescapes requires that each employee is free from drugs or alcohol while performing the tasks by the job.

Please Read Carefully, Initial Each Paragraph and Sign Below
______I hereby  certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I the undersigned applicant have personally completely this application. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be ground for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

_____I hereby authorize Lifescapes to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further authorize the references I have listed to disclose to Lifescapes any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I release Lifescapes my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigations or disclosure.

_____I understand that nothing contained in the application or conveyed during any interview that may be granted or during my employment, if hired, is intended to create and employment  contract between Lifescapes and me. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of Lifescapes, or a two-week notice from you. No promise or representations contrary to the foregoing are binding on Lifescapes unless made in writing and signed by me and a Lifescapes designated representative.

Applicants Signature: ____________________________________________________Date:__________

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PHONE (530) 894-5433 • FAX (530) 893-4763 • EMAIL: INFO@LIFESCAPES.US