APPLICATION FOR EMPLOYMENT/INTERNSHIP

Living Well Balanced, P.C. is an Equal Opportunity Employer and does not discriminate on the basis of Race,
Religion, Sex, Sexual Orientation, National Origin, Citizenship, Age, Marital Status, Disability or any other
characteristic protected by applicable Federal, State and Local Municipality Laws.

Living Well Balanced, P.C. will endeavor to make reasonable accommodation(s) for the known physical or
mental limitations of an applicant, intern or a qualified employee with a known disability unless the
accommodation(s) would impose an undue hardship on our office.

Please print all information in black ink.

Position Applying (or Interning) For Date Available

Personal Trainer ASAP

How did you hear about the position at Living Well Balanced, P.C.?
Indeed.com
Should we thank any individual for referring you to Living Well Balanced, P.C.?

No

PERSONAL INFORMATION
Name in Full Last, First, Middle Initial

Apper, Jared, S
Is any information relating to a change of name, use of an assumed Social Security Number
name, or nickname necessary to check your education or work history?
No 121-82-9379
Address Street, Apartment Number, City, State, Zip Code

30-03 47th st, Apt. #2R, Queens, NY, 11103

Telephone Number Home/Mobile Email
(631)245-9133 [email protected]
If you are under the age of 18, can you provide the required proof of your eligibility to work? Yes No
Are you related in any way to any officer or Past/Present Employee of Living Well Balanced, P.C.? Yes No
If yes, please indicate Name, Position Held and Relationship.
EMPLOYEMENT AUTHORIZATION
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Yes No

Pursuant to the Immigration Reform and Control Act of 1986, all applicants, upon being made an offer of
employment, must produce documents, which are specified by the Federal Government, establishing their
identity and authorization to work in the United States. These documents must be produced no later than
seventy-two hours commencement of employment. You will also be required to sign an Immigration and
Naturalization Service Form I-9, verifying, under oath, your employment authorization.

EDUCATION
Name and Location of Credits Diploma or Degree Type Major Subject
School Completed
High School or Equivalency Yes
No Last Grade Completed

College or University Yes

120 No
Psychology
Graduate/Post Graduate Yes
No

LICENSE/CERTIFICATION
Type of License or Issuing State Number and Date of Date of Current Expiration
Certification Agency Original Last Registration Date
Renewal

Personal Trainer ISSA NY 865687, 4/27/2017 5/1/2019 5/1/2021

FOREIGN LANGUAGES
Language Speak Write Understand Translate
Yes Yes Yes Yes
No No No No
Yes Yes Yes Yes
No No No No
Yes Yes Yes Yes
No No No No
SALARY
Please Indicate your desired salary Hourly: $35 or Annually:
EMPLOYMENT
Please provide a complete history of current and previous employment, starting with the present and working
back. Include, in appropriate sequence, periods of unemployment. Use additional sheets if necessary or
attach resume. Please describe, in detail, the duties and responsibilities or each position listed.

Present or Most Recent Position See Resume

Name of Employer Nature of Business

Self-employed Personal training

Address Street, City, State, Zip Code Telephone
Multiple locations (631) 245-9133
Employment Dates Title/Position Name and Title of Immediate Supervisor
From MM/DD/YY To MM/DD/YY

06/01/18 Personal Trainer Self-employed

Reason for Desiring Change or Leaving Starting Salary Final Salary Number of
Hours Per Week
Inconsistent hours $30/hr $30/hr 10-20
Description of Duties

In charge of managing, booking, scheduling and training up to 30 sessions per week

Number and kind of employees supervised (if any)

May we contact the aforementioned employer? Yes No

Next Previous Position

Name of Employer Nature of Business

Stony Brook University Personal training

Address Street, City, State, Zip Code Telephone

100 Nicolls Rd, Stony Brook, NY 11794 (631) 678-3339

Employment Dates Title/Position Name and Title of Immediate Supervisor
From MM/DD/YY To MM/DD/YY
01/10/2017 12/15/2017 Personal trainer manager Laura Fitzgerald. Director of Fitness
Reason for Desiring Change or Leaving Starting Salary Final Salary Number of
Hours Per Week
Graduated $18/hr $18/hr 15-20
Description of Duties
Maintained staff by recruitng, selecting, orienting, and training all personal training employees

Number and kind of employees supervised (if any)

Supervised 5 other personal trainers, as well as taught a certification course featuring 30
prospective trainers
REFERENCES
List three people other than your relatives who have definite knowledge of your qualification for the position
for which you are applying. Please do not repeat the names of supervisors listed in the employment section.
Name Address: Street, City, Daytime Years Known Occupation
State and Zip Code Telephone

Mike Sheedy (631) 575-7796 3 Business

Curatorial
Amanda Jensen (631) 766-0568 3 Assistant

Marie Case (631) 455-1871 3 Retired

MILITARY RECORD IN U.S. ARMED FORCES
Branch of Service Date of Entry Date of Discharge

Service Schools, Special Training, or Assignments

CONVICTIONS
Have you ever been convicted of a crime in this state or elsewhere? (excluding traffic or parking violations)
Yes No – If yes please explain. (A conviction will not necessarily be a bar to employment, and factors
such as age and time of offense, seriousness and nature of the violation, and rehabilitation will be taken into
account).

APPLICANT’S CERTIFICATION
I certify the information contained herein is correct to my knowledge. I authorize investigation of all matters
contained in this application and agree that any misleading information would be cause for non-employment
or would be sufficient cause for dismissal after my employment. I understand my employment is contingent
upon the receipt by Living Well Balanced, P.C. of satisfactory references and any and all state or company
mandates. Further, I hereby authorize my current/past employers to furnish Living Well Balanced, P.C. with
their employment records. I agree, if employed, to supply Living Well Balanced, P.C. with any such verification
as may be permitted by Federal, State, and Municipality Codes and Regulations and to abide by all Living Well
Balanced, P.C. rules, regulations, systems and policies. I further acknowledge this application is not a contract
of employment and that unless I am employed pursuant to a written employment agreement that provides to
the contrary, I will remain an employee-at-will subject to termination without restriction or limitation.
SIGNATURE
Signed Date

05/06/2019