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Employment Application

An Equal Opportunity Employer
Liberty Services of America, Inc. is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

Please print and fill out all sections

Applicant Information

Applicant Name:
Home Phone:
Email Address:

Current Address:
Number and street:
State & Zip:
How were you referred to Company?:

Employment Positions:
Position(s) applying for:
Are you applying for:  
Temporary work – such as summer or holiday work?
Regular part-time work?
Regular full-time work?
What days and hours are you available for work?
If applying for temporary work, when will you be available?
If hired, on what date can you start working?
Can you work on the weekends?
Can you work evenings?
Are you available to work overtime?
Salary desired: $

Personal Information:
Do you have any friends, relatives, or acquaintances working for Company?
If yes, state name & relationship:
If hired, would you have transportation to/from work?
Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.)
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?
If hired, are you willing to submit to and pass a controlled substance test?
Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?
If no, describe the functions that cannot be performed
(Note: Company complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
If yes, please describe the crime - state nature of the crime(s), when and where convicted and disposition of the case.
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Have you ever been fired from a previous job because of theft on your part?
Is your driver’s license currently suspended, expired or revoked?
Have you had your driver’s license suspended within the last 36 months for any reason?
Have you been convicted of a D.U.I./D.W.I. within the last five (5) years?
Have you been fired from a previous job within the last 36 months because of improper motor vehicle operation?
I hereby attest that I have answered all the above questions truthfully.

Education, Training and Experience:
High School:  
School name:
School address:
School city, state, zip:
Number of years completed:
Did you graduate?
Degree / diploma earned:

College / University:
School name:
School address:
School city, state, zip:
Number of years completed:
Did you graduate?
Degree / diploma earned:

Vocational School:
City, state, zip:
Number of years completed:
Did you graduate?
Degree / diploma?

Rank in Military:
Total Years of Service:
Related details: