Careers - Lakeside Home Care

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3 OH-3 Lakeville, OH
1-866-327-0822

Lakeside Home Care
About Us
Contact Us
Careers

Lakeside Home Care
About Us
Contact Us
Careers

© 2024

Employment Application

Personal Information

Name *

Name

First

First

Last

Last

Street Address *

City *

State

Zip Code

Phone *

Email *

SSN *

Position Applying For *

Desired Salary *

History

Are you a citizen of the United States? *

Yes

No

If yes, are you authorized to work in the United States?

Yes

No

Have you ever worked for this company? *

Yes

No

If yes, when?

Have you ever been convicted of a felony? *

Yes

No

If yes, explain

High School Attended? *

Last Date Attended *

Did you graduate? *

Yes

No

Diploma

Yes

No

College Attended *

Last Date Attended

Did you graduate? *

Yes

No

Degree

Yes

No

References

(Provide at least 1)

Reference #1 Full Name *

Reference #1 Relationship *

Reference #1 Phone *

Reference #1 Company *

Reference #1 Address *

Reference #1 City *

Reference #1 State

Reference #1 Zip Code

Reference #2 Full name *

Reference #2 Relationship *

Reference #2 Phone *

Reference #2 Company *

Reference #2 Address *

Reference #2 City *

Reference #2 State

Reference #2 Zip Code

Reference #3 Full Name *

Reference #3 Relationship *

Reference #3 Phone *

Reference #3 Company *

Reference #3 Address *

Reference #3 City *

Reference #3 State

Reference #3 Zip Code

Work History

(Provide at least 1)

Previous Employer #1 Company *

Previous Employer #1 Phone *

Previous Employer #1 Address *

Previous Employer #1 City *

Previous Employer #1 State

Previous Employer #1 Zip Code

Previous Employer #1 Job Title *

Previous Employer #1 Supervisor *

Previous Employer #1 Starting Salary *

Previous Employer #1 Ending Salary *

Previous Employer #1 Start Date *

Previous Employer #1 End Date *

Previous Employer #1 Responsibilities *

Previous Employer #1 Reason for Leaving *

Previous Employer #1 May we contact for reference *

Yes

No

Previous Employer #2 Company

Previous Employer #2 Phone

Previous Employer #2 Address

Previous Employer #2 City *

Previous Employer #2 State

Previous Employer #2 Zip Code

Previous Employer #2 Job Title

Previous Employer #2 Supervisor

Previous Employer #2 Starting Salary

Previous Employer #2 Ending Salary

Previous Employer #2 Start Date

Previous Employer #2 End Date

Previous Employer #2 Responsibilities *

Previous Employer #2 Reason for Leaving *

Previous Employer #2 May we contact for reference? *

Yes

No

Previous Employer #3 Company

Previous Employer #3 Phone

Previous Employer #3 Address

Previous Employer #3 City *

Previous Employer #3 State

Previous Employer #3 Zip Code

Previous Employer #3 Job Title

Previous Employer #3 Supervisor

Previous Employer #3 Starting Salary

Previous Employer #3 Ending Salary

Previous Employer #3 Start Date

Previous Employer #3 End Date

Previous Employer #3 Responsibilities

Previous Employer #3 Reason for Leaving

Previous Employer #3 May we contact for reference?

Yes

No

Emergency Contact Information

Emergency Contact Information *

Emergency Contact Information

First

First

Last

Last

Emergency Contact Phone Number *

Sign & Date

Disclaimer and Signature I certify that my answers are true and complete to the best of the knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release *

Enter name

Date Signed *

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3 State Route 3 Lakeville, Ohio

We are a non-skilled agency.