LMVA Application for Employment
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accomodation to the application and/or interview process should notify a representative of the Human Resources Department.

This form, once completed and submitted is electronically transferred via secure server and the information it contains remains private and confidential. LMVA will not, under any circumstances, share your personal information with any other individual, company or institution.

Fields in red are obligatory. Please note that the "e-mail" field must contain a VALID e-mail address.
Position(s) applied for Date of Application mm/dd/yyyy
Last Name
First Name
Street Address City State
Telephone No. ###-###-#### Mobile/Beeper, Other Phone No. Zip Code
E-mail Address
If you are under 18, and it is required, can you furnish a work permit?
If no, please explain
Have you ever been employed here before ?
If yes, give dates and position
Are you legally eligible for employment in this country?
Date Available for Work
What is your desired salary range?
Type of employment desired
Are you able to meet the attendance requirements of the position?
Have you ever plead "guily" or "no contest" to, or been commited of a crime?
If yes, please provide date(s) and details
Answering "yes" to these questions, does not constitute an automatic bar to employment. Factors such as the date of the offence, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
Drivers license number if driving is an essential job function
Employment History 1
Provide the following information of your past four (4) employers, assignments or volunteer activities, starting with the most recent.
From To Employer Telephone No.
Starting Job Title Ending Job Title Address
Immediate Supervisor and Title Summarize the nature of work performed and responsibilities
May we contact for reference?
Reason for leaving Hourly Rate/Salary
Start $ per
Final $ per
Employment History 2
From To Employer Telephone No.
Starting Job Title Ending Job Title Address
Immediate Supervisor and Title Summarize the nature of work performed and responsibilities
May we contact for reference?
Reason for leaving Hourly Rate/Salary
Start $ per
Final $ per
Employment History 3
From To Employer Telephone No.
Starting Job Title Ending Job Title Address
Immediate Supervisor and Title Summarize the nature of work performed and responsibilities
May we contact for reference?
Reason for leaving Hourly Rate/Salary
Start $ per
Final $ per
Employment History 4
From To Employer Telephone No.
Starting Job Title Ending Job Title Address
Immediate Supervisor and Title Summarize the nature of work performed and responsibilities
May we contact for reference?
Reason for leaving Hourly Rate/Salary
Start $ per
Final $ per
Skills and Qualifications
Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job related functions in the position for which you are applying.
Educational background (if job related)
High School Name and Location Number of years completed Did you graduate? Course of Study
College Name and Location Number of years completed Did You Graduate? Course of Study
Major Degree
Other Number of years completed Did You Graduate? Course of Study
References
Name TelephoneNumber Years Known
Applicant Statement
Applicant Statement

I certify that all information I have provided in order to apply for and secure work with the employre is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, it's representatives, emlpoyees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment processand all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a bsis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contracry and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I--9 form in this regard.

By electronically submitting this application, I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement

Date