LakesideHealthCare.com

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777A Flower Street
Glendale, CA 91201
818 637-2000

Employment Application

An Equal Opportunity Employer

Position Applied for

Salary Desired

Date of Application

Last Name	First Name	Middle Name
Address	City	State	Zip
Telephone Number(s)	Social Security #:

How did you hear about Lakeside?
Advertisement	(specify)	Friend	Walk-In
Employee	(Name )	Relative	Other

Are you currently employed?	YesNo
What days are you available for work?
What hours are you available for work?
If applying for temporary work, during what period of time will you be available?	From To
Are you available for work on weekends?	YesNo
Would you be available to work overtime, if necessary?	YesNo
If hired, what date can you start work?

PERSONAL INFORMATION

Have you ever applied to or worked for Lakeside before? If yes when?	YesNo
Do you have any friends or relatives working for Lakeside? If yes, state name(s) and relationship:	YesNo

Name	Relationship
Name	Relationship

If hired, would you have a reliable means of transportation to and from work?	YesNo
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)	YesNo
If hired, can you present evidence of your U.S. Citizenship of proof of your legal right to live and work in this country?	YesNo
Are you able to perform the essential function of the job for which you are applying, either with or without reasonable accommodation?	YesNo
If no, describe the functions that cannot be performed. (Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination and to skill and agility tests.)
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for Marijuana-related offenses that are more than two years old need not be listed.)	YesNo
If yes, state the nature of the crime(s), when and where convicted and disposition of the case. (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

REFERENCES

List below three persons not related to you who have knowledge of your work performance within the last three years.

Reference #1

First Name	Last Name	No. of Years Acquainted
Address & Street	City	State	Zip Code
Telephone number	Occupation

Reference #2

First Name	Last Name	No. of Years Acquainted
Address & Street	City	State	Zip Code
Telephone number	Occupation

Reference #3

First Name	Last Name	No. of Years Acquainted
Address & Street	City	State	Zip Code
Telephone number	Occupation

SKILLS AND QUALIFICATIONS
In addition to your work history, what other experiences, skills or qualifications would especially fit for work with our company?

EMPLOYMENT HISTORY
List below all present and past employment starting with your most recent employer (last ten years is sufficient). Account for all period of unemployment you. You must complete this section even if attaching a resume.

Employer	Work Performed
Address
Telephone Number(s)
Position / Job Title
Supervisor	Reason for Leaving
Dates of Employment from to	Weekly Pay Starting: Ending:

May we contact this employer for a reference? Yes No

Employer	Work Performed
Address
Telephone Number(s)
Position / Job Title
Supervisor	Reason for Leaving
Dates of Employment from to	Weekly Pay Starting: Ending:

May we contact this employer for a reference? Yes No

Employer	Work Performed
Address
Telephone Number(s)
Position / Job Title
Supervisor	Reason for Leaving
Dates of Employment from to	Weekly Pay Starting: Ending:

May we contact this employer for a reference? Yes No

EDUCATION, TRAINING AND EXPERIENCE

School	Name and Address	Years Completed	Did you Graduate	Degree Diploma Certificate
High School			Yes No
College / University			Yes No
Vocational / Business			Yes No
Health Care Training			Yes No

Please Read Carefully, Initial Each Paragraph and Sign Below

Initials	I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Initials	I hereby authorize Lakeside, to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other person, corporation, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
Initials	I understand that nothing contained in the application, or conveyed during any interview, which may be granted or during my employment, if hired, is intended to create an employment contract between the Company and myself. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option or either myself or the Company and that no promises or representation contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company's designated representative.

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