How did you learn about this employment opportunity? Acquaintance/friendAmericorpsExternal Website (please specify )Inquired at LSS in-person or by phoneJob Fair (please specify )LSS partner organization or association (please specify )LSS WebsiteReferred by LSS Employee (please specify )Newspaper (please specify )Previous Employee of LSSSchool Related ReferralTemp Employment AgencyOther

Are you at least 18 years of age? (May be required for some positions Yes No

Are you legally authorized to work in the United States? Yes No

Do you have a valid driver’s license? (May be required for some positions)

Have you previously worked for Lutheran Social Service? YesNo

Have you ever been convicted of a felony? If yes, please explain (a conviction will not necessarily disqualify you from employment) Yes No

An individual with a disability or medical condition may request a reasonable accommodation at any time during the application process or during the period of employment. To request an accommodation to support your participation in the interview process, please provide the following information.

I have certified that the information provided on this application is true and complete. I agree that if there is any misrepresentation or omission concerning the information on this application, any offer of employment to me may be withdrawn, and if I have already been hired, my employment may be terminated. I authorize investigation of all statements contained in this application.

I understand that any offer of employment by this agency is contingent upon (1) my providing sufficient documentation necessary to establish my identify and eligibility to work in the United States, (2) successful completion of any pre-employment background investigations that may be required by this employer, (3) proof of a valid drivers license and a satisfactory driving record for those positions involving driving a motor vehicle (Driver Eligibility Below), and (4) Meeting the physical requirements of the position, with or without accommodation.

No promises concerning the nature or length of my employment have been made to me. If I am hired, I understand that I have the right to terminate my employment at any time, and for any reason. I understand that the agency has the right to terminate my employment at any time and for any reason. I understand that if or when my employment is terminated, by the agency or by me, that the agency may respond fully to reference inquiries from prospective employers. I understand that no one employed by the agency has the authority to modify these conditions, except in a written document signed by the President of the agency

By signing my name, I hereby acknowledge that I have read and understand the foregoing agreement.

LSS employment opportunities are available to all without regard for race, color, creed, religion, national origin, sex, sexual orientation, disability, age, marital status or status with regard to public assistance.

The information you provide will not be used in the employment selection process. It will, however, assist us with federal and state affirmative action record keeping and reporting requirements, we ask that you complete this questionnaire. This questionnaire will be kept separate and confidential from your application.

Completion of this information is voluntary. Refusal to provide information will not have a negative effect on your status as an employee or applicant.

Race/Ethnic Group: ---- American Indian or Alaska Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Hispanic or Latino Black or African American (Not Hispanic or Latino) White (Not Hispanic or Latino) Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino)

Sex: ---- Female Male

Disability: ---- No Yes

Veteran of the Vietnam Era: Yes No

Veteran with a Special Disability: Yes No

Thank you for your cooperation and participation.