Apply Here - LCHSLCHS

Today's Date *

Name *

First

Middle

Last

Current Address (Street, City, State, Zip) *

How long at above address? *

Telephone Number *

Are you over 18 years of age? *

Yes
No

If no (above) how old are you?

Social Security # *

How did you hear about this job opportunity?

Position applying for: *

Please indicate specific (other) position you are applying for *

Desired salary *

Hours available to work (check all that apply) *

Full time 40/week
Part time 20/week
PRN as needed less than 20/week

Days available to work (check all that apply) *

Approximate date available for work *

Education (each level) *

Name of School, location, # of years completed, and major/degree earned

Do you have a current, valid driver's license? *

Yes
No

Have you had any accidents during the past 3 years? *

Yes
No

Have you had any moving violations during the past 3 years? *

Yes
No

Personal reference #1 (no relatives or employers) *

Name, Relationship, Company, Address, Telephone #

Personal reference #2 (no relatives or employers) *

Name, Relationship, Company, Address, Telephone #

Additional information/qualification for this position *

Please let us know any additional information that would help us understand why you would be a great fit for our facility?

Work Experience #1 (please list Name, dates of employment, pay, Job title, reason for leaving, and job duties and promotions during this time) *

Most recent 5 years

Work Experience #2 (please list Name, dates of employment, pay, Job title, reason for leaving, and job duties and promotions during this time) *

Most recent 5 years

Work Experience #3 (please list Name, dates of employment, pay, Job title, reason for leaving, and job duties and promotions during this time)

Most recent 5 years

Work Experience #4 (please list Name, dates of employment, pay, Job title, reason for leaving, and job duties and promotions during this time)

Most recent 5 years

May we contact your current employer? *

Yes
No

Important Information-Please read carefully *

I Agree

By signing my name below, I certify that all of the information provided by me in this Job Application, in my resume', and in any interview is true, correct, and complete. I understand and agree that, if I make any false statement or fail to fully answer any question, then Logan County Health Services (LCHS) may reject my application and/or immediately terminate my employment. I authorize LCHS to contact my schools, current or former employers(unless otherwise indicated), references and any other persons and organizations regarding me. I authorize all such schools, employers, references, and other persons and organizations to release accurate information about me to LCHS. I understand that, if LCHS makes an offer of employment to me, I will be required to submit to a drug and alcohol test and a physical/psychological examination, both as permitted by law. I understand that I will be required to authorize the release of the results to LCHS. I further understand that, in connection with the routine processing of my employment application, LCHS may request from a consumer reporting agency, a consumer report and/or an investigative consumer report, including information as to my credit record, character, general reputation, personal characteristics, and mode of living. Upon written request from me, LCHS will provide me with additional information concerning the nature and scope of any such report requested by it, as required by law. I understand that, if I am hired in any position, my employment with LCHS will be terminable "at will". This means that my employment will be for an indefinite period of time and may be terminated at any time, with or without notice, for any reason at all by either me or by LCHS. My status as an "at will" employee can be chaned only if I have a written employment agreement with LCHS that is signed by me and by the Administrator of LCHS. Thus, no employee handbook, benefit plan, verbal promise, or any other statemnet, document or practice can change my status as an "at will" employee. Further, I understand that, within the limits imposed by applicable law, LCHS retains the right to unilaterally change, reduce or eliminate employee benefits, compensations, policies and procedures.

Name *

First

Middle

Last

Verifying you full name acknowledges that you have read and agree to the above statement.