LRH: Online Employment Application

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Employment Application

Items marked with an * are required.

MAIN INFORMATION
Date of Application:
Position Applying For:

PERSONAL INFORMATION
* First Name:
* Last Name:
Please list any other name you have been employed under:
* Address:
* City:
* State:
* Zip:
* Primary Phone Number:
Secondary Phone Number :
Email:
Salary Expectations:

EDUCATION
Highest Level of Education Completed?:
What school was the degree received from?:
Professional Licenses, Certifications & Continuing Education:

WORK EXPERIENCE
Have you previously been employed at this facility?:	YES NO
If yes, please give the dates:

Most Recent Employment
Employed By:
Start Date:
End Date:
Starting Position Title:
Ending Position Title:
Starting Salary:
Ending Salary:
Supervisor's Name:
Supervisor's Title:
Employers Address:
Employers Phone Number:
	Responsibilities and Accomplishments:
	Reason for Leaving:
May we contact this employer?	YES No

Past Employment #1
Employed By:
Start Date:
End Date:
Starting Position Title:
Ending Position Title:
Starting Salary:
Ending Salary:
Supervisor's Name:
Supervisor's Title:
Employers Address:
Employers Phone Number:
	Responsibilities and Accomplishments:
	Reason for Leaving:
May we contact this employer?	YES No

Past Employment # 2
Employed By:
Start Date:
End Date:
Starting Position Title:
Ending Position Title:
Starting Salary:
Ending Salary:
Supervisor's Name:
Supervisor's Title:
Employers Address:
Employers Phone Number:
	Responsibilities and Accomplishments:
	Reason for Leaving:
May we contact this employer?	YES No

AVAILABILITY INFORMATION
Date available to work:
Hours Available:	Full-Time (32+ hours per week) Part-Time PRN/Casual
Are you available to work?:	Days Nights Weekends

How did you hear about the open position at Lake Regional Healthcare?	Lakes Regional Healthcare Employee (please specify employee) Newspaper (please specify newspaper) Internet Search