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Application

APPLICATION FOR EMPLOYMENT

LIFE Senior Services
5950 East 31st Street Tulsa, OK 74135-5114
The mission of LIFE Senior Services is to provide information, education and services that promote independence, quality of life and dignity for residents of northeastern Oklahoma.

Required field(s) are indicated by an *.

PERSONAL INFORMATION

* Date / / (MM/DD/YYYY)
* Date Available / / (MM/DD/YYYY)

(A yes my not automatically disqualify you, but a false statement or omission of information will disqualify you.)

EDUCATION




Date Received / / (MM/DD/YYYY)



Date Received / / (MM/DD/YYYY)



Date Received / / (MM/DD/YYYY)


If a professional license or certificate is required or related to the position for which you are applying, complete the following.
RN, LPN, CMA, CNA, etc.
Date Issued / / (MM/DD/YYYY)
state or other authority
City & State



RN, LPN, CMA, CNA, etc.
Date Issued / / (MM/DD/YYYY)
state or other authority
City & State

OTHER INFORMATION

EMPLOYMENT HISTORY

List all jobs (including military service) beginning with your most recent employer.

* From / / (MM/DD/YYYY)
(MM/DD/YYYY) or Current



From / / (MM/DD/YYYY)
(MM/DD/YYYY) or Current



From / / (MM/DD/YYYY)
(MM/DD/YYYY) or Current

OTHER INFORMATION

REFERENCES









*

AFFIRMATIVE ACTION AND EEO DATA COLLECTION


INSTRUCTIONS TO APPLICANTS
LIFE Senior Services is an equal opportunity employer. As part of our efforts to ensure fair treatment of individuals with disabilities; veterans; people of all races, color, national origins, religions, ages; women and other minorities, we ask applicants to supply the following information. However, you do not have to complete this form to be considered for employment. Any information volunteered will be kept confidential and will not be used to make hiring decisions.

Date / / (MM/DD/YYYY)

GENDER

RACE

                        

VETERAN

If you are a veteran, please supply the following information.
Dates of Service / / (MM/DD/YYYY) TO / / (MM/DD/YYYY)
(served in Vietnam at any time from February 28, 1961 to May 7, 1975)
(served in the armed forces, but not in Vietnam, at any time from August 5, 1964 to May 7, 1975)

ACCOMMODATIONS

If you have a disability that requires accommodation to perform this position, please explain what accommodations would allow you to perform this job successfully