Employment Application – Londonderry Village

Personal Information

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone #

Cell Phone #

Personal Email Address

Education Information

Schools Attended - Include Current

School Level(High School/College/Vocational)

Address

Major/Course of Study

Did you Graduate?

Press the (+) icon on the right to add additional schools.

Professional License/Certification

Type

Number

State

List any professional organization membership(s), honors received, extra-curricular activities, and other qualifications you have which are related to the position for which you are applying. (Do not list any information which may indicate race, religion, gender, ethnic background, national origin, age, genetic information, disability, or marital status).

Press the (+) icon on the right to add additional entries.

How did you hear about out Employment Opportunities?

Employee Referral

Friend/Relative

Walk-in

Job Fair

Previous Employment at LV

Internet

Other

If Employee/Friend Referral, please list who referred you:

Personal References

List the names of three persons not related to you, whom you have known at least one year, who will provide a personal reference.

Name

Address

Phone Number

Years known and how

Press the (+) icon on the right to add additional entries.

Employment History

Complete this section even if you are including a resume. List names of employers beginning with your current or most recent employer.

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Employer Phone

Position

Employment Start Date

Employment End Date

Ending Pay Rate

May We Contact?

Supervisor

Reason for Leaving

Duties

Employer #2

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Employer Phone

Position

Start Date

End Date

Ending Pay Rate

May we contact?

Supervisor

Reason for Leaving?

Duties

Employer #3

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Employer Phone

Position

Start Date

End Date

Ending Pay Rate

May we contact?

Supervisor

Reason for leaving?

Duties

Applicant Statement

Resume Upload

Accepted file types: pdf, doc, docx, Max. file size: 200 MB.

Consent(Required)

I have read and I fully understand the foregoing and seek employment under those conditions.

I understand that my signature below indicates that all information contained in this application and other materials
submitted is true, correct and complete. I understand that any misrepresentation or material omission made by me on
this application will be sufficient cause for cancellation of this application or, if I am employed, sufficient cause for
termination of employment whenever the misrepresentation or material omission is discovered.
I voluntarily give Londonderry Village, its agents, representatives, and employees the right: to make a thorough
investigation of my past employment, education, and activities; contact and obtain information from all references,
employers, and educational institutions; conduct criminal background checks and/or drug testing; verify my social
security number and related information, drivers license and vehicle records, criminal history record information,
professional license/certification and education; and to take such other actions as it deems necessary to otherwise verify
the accuracy of the information contained in this application.
I authorize my prior employers and references to release all records and information relating in any way to my prior
history and employment.
I hereby release from any and all liability and responsibility Londonderry Village and its agents, employees and
representatives for seeking, gathering and using such information; and I hereby release from any and all liability all
persons, companies and corporations and their agents, employees and representatives for furnishing such information.
I also understand that any job I may be offered is not for any set period of time and that if I am hired that my
employment is “at will” employment, and that either party may terminate the employment relationship at any time for
any reason or for no reason.
I understand that this application does not constitute an agreement or contract for employment for any specific period
or definite duration.
Except as otherwise provided herein, I also understand that any changes to the terms and conditions of this application
must be made in writing and signed by the parties hereto.
I have read and I fully understand the foregoing and seek employment under those conditions.

Applicant Signature

Date

Personal Information

Employment Information

Education Information

Professional License/Certification

Personal References

Employment History

Employer #2

Employer #3

Applicant Statement