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APPLICATION FOR EMPLOYMENT
Lincoln Self Reliance, Inc.

LSR is an Equal Opportunity Employer. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. 

All fields marked with an  are required. 

 

Position(s) Applied For
How did you learn about us?

Other:
Last Name
First Name
Middle Name
Physical Address
City
State
Zip
Mailing Address
City
State
Zip
Telephone Number(s)
Email Address
Best time to contact you:
 
Have you ever filed an application with us before?
If Yes give date
Have you ever been employed with us before?
If Yes give date
Do any of your friends/relatives work at, or receive services from, LSR, Inc.?
If Yes, state name, relationship and location
Are you currently employed?
 
May we contact your present employer?
 
Date available for work
 
What is your desired salary range?
 
Are you available to work:
 
 
If temporary, specify dates From - To:
Can you travel if a job requires it?
 
WORK EXPERIENCE
Employer
Date From
Date To
Work Performed
Address
Phone
Job Title
Salary From
Salary To
Supervisor
May We Contact?
Reason For Leaving

 

Employer
Date From
Date To
Work Performed
Address
Phone
Job Title
Salary From
Salary To
Supervisor
May We Contact?
Reason For Leaving

 

Employer
Date From
Date To
Work Performed
 
 
Address
Phone
Job Title
Salary From
Salary To
Supervisor
May We Contact?
Reason For Leaving

 

Aditional
Employer
City/State
Date From
Date To
Pay Start
Pay Final
Reason for Leaving
Employer
City/State
Dates From
Date To
Pay Start
Pay Final
Reason for Leaving
Employer
City/State
Dates To
Dates From
Pay Start
Pay Final
Reason for Leaving

 

Describe any job related training, apprenticeship, skills or professional memberships
EDUCATION
High School
Name/Address of School
Course of Study
No. Years Completed
Diploma/Degree
Undergraduate College
Name/Address of School
Course of Study
No. Years Completed
Diploma/Degree
Graduate / Professional
Name/Address of School
Course of Study
No. Years Completed
Diploma/Degree
Other / Specify
Name/Address of School
Course of Study
No. Years Completed
Diploma/Degree
REFERENCES:
List the names, addresses, and telephone numbers of at least three (3) individuals, not related to you or previous employers, who can provide information about your skills, abilities, education, and experience:
Reference 1
Reference 2
Reference 3
DRIVING RECORD
Do you have a valid Drivers License?
 
Number
Class
Expiration

 

In the last five (5) years have you been the driver in an automobile accident?
 

 

 
Date
Location

 

Recent traffic violations?
 
Date
Location
Type

 

Have you been listed on a child abuse/neglect registry in Wyoming or any other state?
If yes, please give specifics:

 

Have you been convicted of any felony, public indecency, a violation of the Wyoming Controlled Substance Act, or driving under the influence of alcohol or a controlled substance?
If yes, please give specifics:

Prior to or upon being hired for this position, background record reviews WILL be conducted on you via fingerprinting with the FBI, DCI (Wyoming Division of Criminal Investigation), and DFS (Department of Family Services) registry review. Fingerprint cards will be provided to you. Other background reviews may be conducted including a pre-employment drug screening.

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. (See enclosure - Essential Functions of Position).  Click here for a DSP (Direct Support Professional) Job Description (Opens in new window/tab)
 
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the primary duties involved in the job or occupation for which you have applied? A review of the primary duties involved in such a job or occupation has been given.

 

Did you complete this application yourself?
If no, who did and why?

Lincoln Self Reliance    |    DarrelS@lsrservices.org    |    Phone 307-885-1577    |    Fax 307-885-2577