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Lincoln Self Reliance has received a three-year CARF accreditation for Community Services: Community Integration, Housing, and Supported Living.

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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.  NOTE:  An email address is required to apply online.  You will receive a confirmation copy of your application via email.  All fields marked with an  are required.
 

Position(s) Applied For

Date of Application (mm/dd/yy)
How did you learn about us? (Advertisement, friend, Inquiry, Employment Agency, Relative, etc.)
 
Last Name First Name Middle Name
Address (Street & PO Box) City State Zip Code
Telephone Number(s) E-mail Address Social Security Number (Voluntary)
- -
 
Best time to contact you is?
Have you ever filed an application with us before? Yes NO
If Yes, Give Date:
Have you ever been employed with us before? Yes NO
If Yes, Give Date:
Do any of your friends/relatives work at, or receive services from, LSR, Inc.? Yes NO
If Yes, state name, relationship and location
Are you currently employed? Yes NO
May we contact your present employer?     Yes NO
Date available for work 
What is your desired salary range?
When are you available to work?

 

Full-Time, Part Time, Temporary, etc.
Please Indicate mornings, afternoons, nights, weekends, etc.
If Temporary, please indicate dates available
Can you travel if a job requires it? Yes NO

Work Experience

Start with your present or last job, listing the three (3) most current. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

 
Employer Dates Employed Work Performed
  From (mm/dd/yy) To (mm/dd/yy)  
Address Telephone Number(s)

Starting/Present Job Title

Hourly Rate/Salary
  Starting Final  
 
Supervisor Reason for Leaving May We Contact?
Yes No
 
 
Employer Dates Employed Work Performed
  From (mm/dd/yy) To (mm/dd/yy)  
Address Telephone Number(s)

Starting/Present Job Title

Hourly Rate/Salary
  Starting Final  
 
Supervisor Reason for Leaving May We Contact?
Yes No
 
 
Employer Dates Employed Work Performed
  From (mm/dd/yy) To (mm/dd/yy)  
Address Telephone Number(s)  
 

Starting/Present Job Title

Hourly Rate/Salary  
  Starting Final  
 
Supervisor Reason for Leaving May We Contact?
Yes No
 
Additional
 
Name of Employer Date Employed From (mm/dd/yy) Date Employed
To
(mm/dd/yy)
City / State
Reason for Leaving Starting Pay Final Pay
   
 
Name of Employer Date Employed From (mm/dd/yy) Date Employed
To
(mm/dd/yy)
City / State
Reason for Leaving Starting Pay Final Pay
   
 
Name of Employer Date Employed From (mm/dd/yy) Date Employed
To
(mm/dd/yy)
City / State
Reason for Leaving Starting Pay Final Pay
   
 
Describe any job related training, apprenticeship, skills, or professional memberships:
Education
Type of School Name / Address of School Course of Study No. Years Completed Diploma / Degree
High School
Undergraduate College
Graduate / Professional
Other / Specify
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:
           
1)
2)
3)
Driving Record
Do you have a valid Wyoming Drivers License? Yes No
Number Class
Expires  
In the last five (5) years have you been the driver in an automobile accident?  
Date(s) Location(s)
Traffic Violations:      
Date(s) Location(s)
Type
Background Information
Have you been listed on a child abuse/neglect registry in Wyoming or any other state? Yes No
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? Yes No
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.
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. Yes No
 
Did you complete this application yourself? Yes No
If no, please give specifics:  
 
 
Please read each statement carefully before submitting:

I understand that any misrepresentation or falsifications may result in removal from consideration of employment. I give LSR, Inc. and its authorized agents permission to verify any job-related information given with this application.

I understand that I may be required to submit to drug and alcohol testing as part of the pre-employment process or as a condition of continued employment if hired by LSR, Inc.

I understand that if hired by LSR, Inc., I will be an at-will employee.  That means that this application, verbal statements by management, or subsequent employment does not create an expressed or implied contract of employment, or continued employment, nor does it guarantee employment for any definite period of time.

LSR requires all employees to sign a non-compete work agreement upon hire date. 

Attach a copy of your resume
 

   


Lincoln Self Reliance, Inc.
"Serving Individuals with Disabilities in their Local Communities"

1038 South Washington Street,  Post Office Box 1449,  Afton, Wyoming  83110
Phone: 307-885-1577  |   Fax: 307-885-2577   |   Email: DarrelS@lsrservices.org