* = Required Information

GENERAL DATA

Yes No

PERSONAL DATA

Yes No
Yes No
Yes No

Note: Conviction is not an automatic bar to employment. Each case will be considered on its own merits.

PROFESSIONAL & TECHNICAL APPLICANTS ONLY

SKILLS

Yes No
Yes No

Military experience in armed forces of the U.S. or in a state Wide (U.S.).

Yes No

EDUCATION

High School

College

Trade, or Other Prof. School

WORK EXPERIENCE –

Yes No
Yes No
Yes No
Yes No
Yes No

* I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by Lorddys Healthcare Solutions unless I have indicated to the contrary. I authorize the references listed above to provide any and all information concerning my previous employment and any pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to Lorddys Healthcare Solutions as well as from the use or disclosure of such information by or any of its agents, employees, or representatives.
* I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, in my dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of the company and agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of the company. I understand that no employee or representative of the company other than the president of the company 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. Further, the president of the company may not alter the at-will nature of the employment relationship unless he/she does so specifically in writing. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant's identity and legal authority to work in the U.S.
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