↑ Return to Employment

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:
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


Name and Address of School
Major and Degree
    yes or no


High School
Graduate School

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:
Company Name 2:
Address, City, State, Zip Code;
Start Date
End Date;
Start Pay
Final Pay
Name of Supervisor
Title or Position
Major Job Duties-:
Reason for Leaving
Company Name 3:
Address, City, State, Zip Code-
Start Date-
End Date-
Start Pay-
Final Pay-
Name of Supervisor-
Title or Position-
Major Job Duties-

Personal References

Please List Three Personal References

Name (1)
Occupation (1)
Address (1)
Phone (1)
Occupation (2)
Address (2)
Name (3)
Occupation (3)
Address (3)
Phone (3)

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?


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.


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