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Job Application

Applicant Information


Referral Information

How Did You Hear About Us?


Are You 18 or Older?
Have You Lived Outside of PA at Anytime During the Last 24 Months?
If Yes, you will be required to submit an FBI Clearance
Are You Legally Eligible For Employment?
Have You Been Convicted of a Crime (Excluding Misdemeanors & Summary Offenses) That has not been Annulled, Expunged, or Sealed by a Court?
Conviction will not necessarily disqualify for employment
Have You Ever Worked for Us or Filled an Application for Us Before?


On What Date Will You Be Available to Begin Work?
What Hours/Days Are You Available to Work?


Do You Have A High School Diploma or GED
Business/Trade/Technical School
Did You Graduate?
Did You Graduate?
Did You Graduate?

Special Skills/Qualifications

Employment Questionnaire

Do You Have a Valid PA Driver's License?
Have You Had a Physical Done within the Last 12 Months?
Have You Had a Criminal Clearance Submitted within the Last 12 Months?
Have You Had a Child Abuse Clearance Submitted within the Last 12 Months?
Have You Had Any Moving Violations/Accidents in the Past 5 Years? (If Yes, Please Specify)

Employment Experience

Employer #1
Employed From
Weekly Pay Start
May We Contact this Employer?
Employer #2
Employed From
Weekly Pay Start
May We Contact this Employer?
Employer #3
Employed From
Weekly Pay Start
May We Contact this Employer?


Reference #1
Reference #2
Reference #3


Do You Have Any Relatives/Friends Currently Working with Us? (If Yes Please List Them)
Friend/Relative #1
Friend/Relative #2
Friend/Relative #3


I hereby certify that the information provided by me in this application is true, correct, and complete. I understand that I may be refused employment or terminated from employment due to my falsification or my failure to provide complete information. I authorize the investigation of all statements contained in this Application for Employment as may be necessary in arriving at an employment decision and release Lifestyle Support Services, Inc. from any and all liability associated with such an investigation. I authorize the companies, schools, and persons named herein to release any employment and background information they have regarding me, whether or not it is in their records, and hereby release said companies, schools, and persons from all liability for releasing such information.

I understand that Lifestyle Support Services, Inc. has an obligation to all its employees, customers, and the public at large to ensure safety in the workplace, on company premises, and in the delivery of its services. Therefore, I hereby consent to post-offer, pre-employment screening. I understand that successful completion of the post-offer, pre-employment screening is required, including the submission of applicable criminal history and child abuse clearances. I understand that to be minimally eligible for employment I must be over the age of 18, possess a high school diploma/GED, and have a valid PA driver’s license.

I understand that if I am employed by Lifestyle Support Services, Inc., I am not guaranteed employment for any specified period of time and that my employment may be terminated by Lifestyle Support Services, Inc. or myself at any time, for any reason, with or without notice. I understand that Lifestyle Support Services, Inc. does not offer any contract or guarantees of employment, express, implied or otherwise and therefore, any such perceived agreement would be null and void unless recorded in writing and signed by myself and the President of Lifestyle Support Services, Inc. I also understand that completion of this application, which will remain in effect for ninety days, does not indicate positions are open or obligate Lifestyle Support Services, Inc. in any way.

I Have Read & Agree with this Statement
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