Employment Form

* = Required Information

GENERAL DATA

First Name *

Last Name *

Address *

City *

State

Zip Code *

Home Phone Number

Years at Above Address

Drivers Lic. No. (If Job Involves Driving)Exp. Date

Social Security No.

Date of Application

Position Applied for

Full or Part-Time

Shift/Hrs. Available

If employed in the position for which you have applied would you be in a supervisory or subordinate relationship to any relative or member of your household?

Yes

PERSONAL DATA

If under 18 years of age, can you submit a work permit after employment?

Yes

If you are not a U.S citizen, have you the legal right to remain permanently in the U.S.?

Yes

If No, Visa Number

List memberships in professional organizations which you feel would enhance your application, excluding any names that would indicate the race, religious creed, color, national origin, or ancestry of its members.

How did you learn of this job opening?

Have you ever been convicted of a crime other than traffic infractions?

Yes

If "YES", please explain:

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

PROFESSIONAL & TECHNICAL APPLICANTS ONLY

Professional Lic. No.

Epiration Date

Type of License

State

Professional Lic. No.

Epiration Date

Type of License

State

SKILLS

Type

Yes

WPM

Shorthand

Yes

WPM

Machines Operated

Other Training/Skills, Including Bilingual Ability

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

Service Branch

Initial Rank

Final Rank

Specially

Is there any reason why you would be unable to perform or to safely perform any of the duties of the position for which you have applied, as set forth on the Lob description for that position?

Yes

If "Yes" you may explain

EDUCATION

High School

Name of School & Address

No. of Yrs.

Course or Major

Diploma/Degree

College

Name of School & Address

No. of Yrs.

Course or Major

Diploma/Degree

Trade, or Other Prof. School

Name of School & Address

No. of Yrs.

Course or Major

Diploma/Degree

WORK EXPERIENCE – BEGINNING WITH MOST RECENT JOB. PLEASE FULLY ACCOUNT FOR ALL TIME, INCLUDING PERIODS OF UNEMPLOYMENT AND ANY PRIOR EMPLOYMENT BY THIS FACILITY. (USE ADDITIONAL SHEET FOR ADDITIONAL EMPLOYMENT INFORMATION.)

Name of Last/Present Employer

Street Address

City

State

Phone

Supervisor's Name

Supervisor's Title

Your Title

Your Position & Duties

May We Contact Now for Reference Information?

Yes

Starting Date

Ending Date

Starting Pay

Ending Pay

Reason for Leaving

Name of Next to Last Employer

Street Address

City

State

Phone

Supervisor's Name

Supervisor's Title

Your Title

Your Position & Duties

May We Contact Now for Reference Information?

Yes

Starting Date

Ending Date

Starting Pay

Ending Pay

Reason for Leaving

Name of Second to Last Employer

Street Address

City

State

Phone

Supervisor's Name

Supervisor's Title

Your Title

Your Position & Duties

May We Contact Now for Reference Information?

Yes

Starting Date

Ending Date

Starting Pay

Ending Pay

Reason for Leaving

Name of Third to Last Employer

Street Address

City

State

Phone

Supervisor's Name

Supervisor's Title

Your Title

Your Position & Duties

May We Contact Now for Reference Information?

Yes

Starting Date

Ending Date

Starting Pay

Ending Pay

Reason for Leaving

Name of Fourth to Last Employer

Street Address

City

State

Phone

Supervisor's Name

Supervisor's Title

Your Title

Your Position & Duties

May We Contact Now for Reference Information?

Yes

Starting Date

Ending Date

Starting Pay

Ending Pay

Reason for Leaving

Attach Resume

* 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.

Date