Yes No

Will you work overtime if asked?

Yes No Yes No

Yes No

Yes

No

Yes

No

Yes

No

Do you have a family member (parents, spouse, brother, sister, son, daughter, father or mother-in-law, brother or sister-in-law, son or daughter-in-law) who serves on Life Time’s Board of Directors?

FirstLast Name

DID YOU GRADUATE?

COURSE OF STUDY

Pay Expected

Street Address

City, State, Zip

Home Phone

Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, or handicap.

Please fill in both sides of applicationAPPLICATION FOR EMPLOYMENT

Alternate PhonePERSONAL

When will you be available to begin work?

Middle Date

NO. OF YEARS COM-

PLETED

Are you legally eligible for employment in the United States?

If Yes: Month _______ Year_______

If not, what hours can you work?

Apart from absence for religious observances, are you available for full-time work?

EDUCATION

SCHOOL

College

High

Elementary

Please list other special training or skills that you believe qualify you for the position.

DEGREE OR DIPLOMANAME AND LOCATION OF SCHOOL

MEMBERSHIP IN PROFESSIONAL OR CIVIC ORGANIZATIONS(Exclude those which may disclose your race, color, religion, or national origin.)

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged, or sealed by a court? Yes No If Yes, describe in full.

State names of relatives and friends working for us other than your spouse.

Besides the local newspaper, where have you looked for job openings?

Have you ever been interviewed for employment with us?

Position Desired How did you hear about our agency?

Position:

4/09, 10/12, 2/13, 08/17

Reason for Leaving

To

Weekly Pay

Start Last

Address

State Job Title, and Describe Your Work Reason for Leaving

Company Name

Address

State Job Title, and Describe Your Work

Your Name While Employed

State Job Title, and Describe Your Work Reason for Leaving

Company Name

EMPLOYMENT HISTORYPlease give accurate, complete full-time and part-time

employment record. Start with present or most recent employer.

1

Phone Number

Employed (State Month and Year)

From

Name of Supervisor

Company Name

State Job Title, and Describe Your Work

Start Last

Name of Supervisor

Reason for Leaving

Address

Your Name While Employed

Weekly Pay

2

Phone Number

Employed (State Month and Year)

From To

Weekly Pay

Name of Supervisor

Phone Number

Employed (State Month and Year)

From To

Your Name While Employed3

Company Name

Phone Number

4 Name of Supervisor Your Name While Employed

Start Last

Start Last

Address

Employed (State Month and Year)

From To

Weekly Pay

Phone #

List 3 References other than family members or former employers.Name

Address

Phone #

Name

Address

Address

RE F ERENCE

We may contact the employers listed above unless you indicate those you do not want us to contact.

DO NOT CONTACTEmployer Number(s): Reason:

Phone #

Name

4/09, 10/12, 2/13, 08/17