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Online Application

Attention:  Applicants YOU MUST CLICK the Submit Application button before completing and submitting the affirmative action form. Both forms must be completed and submitted for valid applications.

Application for Employment

Position(s) Applied For: *
Name:*
Email Address:
Address:
City:
State:
Zip Code:
Phone Number: *
Social Security #
Are you eligible for employment in the U.S.A.? yes or no *
Are you of the legal age to work? yes or no*
Full or Part-Time Placement Desired?
Were you previously employed by us? Yes or No, If yes when?
Date you will be available to work?
Highest level of education completed:
Skills, Experiences, or Qualifications

Education

  Please list the following:

Name and Address of School
Major and Degree
Graduate 
    yes or no

GPA

High School
College/University
Graduate School
Other/Military

Employment History

Beginning with most recent. Company Name 1:
Address, City, State, Zip Code
Phone :
Start Date:
End Date:
Start Pay:
Final Pay:
Name of Supervisor:
Title or Position:
Major Job Duties:
Reason for Leaving:
Beginning with most recent. Company Name 2:
Address, City, State, Zip Code (2)
Phone :(2)
Start Date: (2)
End Date:(2)
Start Pay:(2)
Final Pay:(2)
Name of Supervisor:(2)
Title or Position:(2)
Major Job Duties:(2)
Reason for Leaving:(2)
Beginning with most recent. Company Name 3:
Address, City, State, Zip Code (3)
Phone :(3)
Start Date: (3)
End Date:(3)
Start Pay:(3)
Final Pay:(3)
Name of Supervisor:(3)
Title or Position:(3)
Major Job Duties:(3)
Reason for Leaving:(3)

Personal References

Please List Three Personal References

1-Name:
1-Occupation
1-Phone:
-
1-Address:
2-Name:
2-Occupation:
2-Phone:
-
2-Address:
3-Name:
3-Occupation:
3-Phone:
-
3-Address:
Have you ever been cited for a traffic violation within the last 7 years? If yes, please give any dates and details: **
Are you currently subject to ANY criminal charges? If yes, please give any dates and details: **
Have you ever plead guilty or “no contest” to a crime? (Include DUIs or other major traffic offenses) Yes or No**
Have you ever been terminated or asked to resign from any job? If yes, please explain the circumstances: **
May we contact your employers? If no, please explain: **
How did you learn about our open position?

APPICANTS STATEMENT

I understand that Lawrence Health Services is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, religion, handicap or disability, or any other category protected by law.
In making this application for employment, I understand that the facility may investigate any driving record and my criminal record and that an investigative consumer report may be made, whereby information is obtained through personal interviews with my neighbors, friends or others with whom I am acquainted. This inquiry includes information as to my character, general reputation, personal characteristics, financial responsibility, and mode of living. I understand that I have a right to make a written request with­in a reasonable period of time to receive additional detailed information about the nature and scope of this investigative report.
I authorize former and present employers, work and personal references listed in the application, and any other individuals I may name, to give the facility or its designee any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release such parties from all liability for any damages that may result from furnishing same to the facility.

I understand that the facility reserves the right, to the extent permitted by law, to require a medical examination including, but not limited to, any drug screening test, urinalysis, blood test, breathalyzer, or other procedure, of any applicant or employee either prior to employment or any time during employment and I hereby give my consent to any such test or examination. I consent to the release of the results of any such test or examination to the facility.

I understand that this employment application and any other facility documents are not promises of employment. Should I be employed, I understand that my employment will be on a trial period for ninety days from the date of my hiring. I further understand that, if I am employed, I can terminate my employment with or without cause and with or without notice, at any time, and that the facility has a similar right. I understand that no manager or representative of the facility has any authority to enter into any agree­ment for employment for any specified period of time, or to make any agreement contrary to the foregoing, except that the Administrator may do so in writing.

The information given by me in this application is true and complete in all respects, and I agree that if the information is found to be false, misleading or unsatisfactory in any respect (in the exclusive judgment of the facility) that I will be disqualified from consid­eration for employment or subject to immediate dismissal if discovered after I am hired.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A PERIOD OF NINETY (90) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY. DO NOT SUBMIT YOUR APPLICATION UNTIL YOU HAVE READ AND UNDER­STAND THIS STATEMENT.

By submitting your application, you hereby agree to the above statement and its terms listed within.

Click the Submit Application button below before proceeding on:

 


AFTER application submission please fill out and submit the following affirmative action form:

APPLICANT EEO: EEO-1 Voluntary Self Identification Form Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. Lawrence Health is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our Affirmative Action Program. Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as disabled, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program and EEO-1 reporting as applicable. We are a company that values diversity. We actively encourage women and minorities Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment. This information will be kept separate from all other personnel records only accessed by Human Resources Department. Please return completed forms to the Human Resources Department. Racial/Ethnic Origin (You may mark one or more of the following):

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
American Indian or Alaska Native – a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
I elect not to identify:
What is your sex? Male or Female
Name:
Date: