Position Application

    Application Information


    For which schedules are you available?

    Job-Related Skills

    If the job requires, do you have the appropriate valid drivers license?
    Have you had any moving violations?

    Have you been given a job description or had the essential functions of the job explained to you?
    Do you understand these essential functions?
    Can you perform the essential functions of this job with or without reasonable accommodations?


    Have you been convicted of a crime, including a plea of guilty or nolo contentere? If so, please describe in the boxes below. Conviction will not necessarily be a bar to employment. In accordance with ALSM policy and applicable state and federal laws, factors such as age at time of the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed. YesNo

    Incident 1

    Incident 2

    Additional Information

    Previous Employers

    Most Recent Employer

    Are you currently working for this employer?
    If yes, may we contact?

    Second Most Recent Employer

    Third Most Recent Employer


    Reference 1

    Reference 2

    Reference 3


    High School






    Certification and Release

    Have you ever worked for Allegheny Lutheran Social Ministries?

    I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment.

    I affirm that I have a genuine intent and no other purpose for applying for a job with ALSM. Furthermore, I understand that just as I am free to resign at any time, ALSM reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of ALSM has the authority to make any assurances to the contrary.

    I authorize ALSM and / or its agents, including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background which is job or performance related or other information and hereby release any employers, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. Furthermore, in consideration of my application, I release ALSM from any liability for any damage whatsoever in receiving and utilizing this information.

    I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

    I understand that ALSM is an equal opportunity employer, that ALSM does not discriminate in employment, and that no question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state, or federal law.

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