Last Name      First Name     Middle    

Home Telephone                  Example: 555 555 5555               E-mail Address 

 Present Address

Street Address   City     State     Zip Code   
 

If you have lived at your current address less than 5 years please include previous address.                                                                                                     

Previous Address

Street Address   City     State     Zip Code   
 

Religious Affiliation                      Are you 18 years or older?   Yes  No

Name, address and pastor of congregation   

Type of work or position applied for      Referred by   

Interested in             Full-time       Part-time       Summer                   Salary required   

Date available for work  

Location  

Have you previously applied to LCMS?                 Yes     No     If yes, give date  

Are you a citizen of the United States or do you have a valid authorization to work in the United States?             Yes  No

Have you ever been convicted, pleaded guilty or pleaded “no contest” to any crime, other than traffic violations in the pasts? Yes  No   If yes, please explain

Have you ever been discharged or asked to resign by a previous employer?    Yes  No If yes, please explain

List your complete employment record including temporary, regular and part-time in date order with most recent first. List military service, if applicable, as part of employment record.

MOST RECENT EMPLOYER Are you currently working for this employer  Yes         No                      If yes, may we contact?  Yes          No

Company Name                          Telephone 

Street Address      City         State       Zip Code

Starting Position Title   Ending Position Title

Supervisors Name               Title          Part-time   

Employed From       Beginning Salary        Ending Salary       Full-time  

Brief job description   

 If you were employed under a different name, give that name in full   

Company Name                          Telephone 

Street Address      City         State       Zip Code

Starting Position Title   Ending Position Title

Supervisors Name               Title          Part-time   

Employed From       Beginning Salary        Ending Salary       Full-time  

Brief job description   

If you were employed under a different name, give that name in full  

Company Name                          Telephone 

Street Address      City         State       Zip Code

Starting Position Title   Ending Position Title

Supervisors Name               Title          Part-time   

Employed From       Beginning Salary        Ending Salary       Full-time  

Brief job description   

 If you were employed under a different name, give that name in full   

Account for all periods of two weeks or more for which you have been without work in the last five years.

In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance and experience, along with reasons for termination of past employment. I understand that, as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: workers’ compensation injuries, driving record, criminal record, education, credentials, credit and references. I voluntarily and knowingly authorize the company, and/or its agents, to verify any aspect of the information contained in my employment application or through public or private sources. I further understand that misrepresentations or omissions in my employment application may be cause for rejection or subsequent dismissal if I am hired.

Medical and workers’ compensation will only be requested in compliance with the Federal Americans with Disabilities Act (ADA). According to the Fair Credit Reporting Act (FCRA), I am entitled to know if employment is denied because of information obtained by my prospective employer by a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.

I voluntarily and knowingly authorize any former employer, person, firm, corporation, school or government agency, its officers, employees and agents to release to you or your agents any and all information concerning my former employment. I understand that the employment information may include, but is not necessarily limited to, performance evaluation and reports, job descriptions, disciplinary reports, letters of reprimand and opinions regarding my suitability for employment possessed by it.

I voluntarily and knowingly fully release and discharge, absolve, indemnify and hold harmless you, your agents and any former employer, person, firm, corporation, school or government agency, its officers, employees and agents from any and all claims, liability, demands, causes of action, damages, or costs, including attorney’s fees, present or future, whether known or unknown, anticipated or unanticipated, arising from or incident to the disclosure or release of any such information to you, your agents, or consumer reporting agency.

I hereby authorize you to procure a consumer report as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to procure consumer reports at any time during my employment period.

Signature                                                                            Date  

The following information is required by law-enforcement agencies and other entities for positive identification process when checking public records. It is confidential and will not be used by any other purposes.

After you submit the application you will be given instructions for sending your Resume' and Cover Letter.  If you receive an error message click cancel, once we have received your application we will send you a confirmation e-mail.