Careers Employment Application Thanks for your interest in employment with Lakeside Home Care. Please fill out and send the form below. (Check our Facebook page and newspaper ads for most-up-to-date job postings.)First Name *Middle *Last Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Phone *Email *Date Available *Social Security Number *Desired Salary *Position Applied for *Are you a citizen of the United States? *YesNoIf no, are you authorized to work in the United States? *YesNoHave you ever worked for this company? *YesNoIf yes, when? *Have you ever been convicted of a felony? *YesNoIf yes, explain. *EducationHigh School *High School Address *From *To *Did you graduate? *YesNoDiploma *YesNoCollege *College Address *From *To *Did you graduate? *YesNoDegree *YesNoReferences Please list 3 professional references.Full Name *Relationship *Company *Phone *Address *Full Name *Relationship *Company *Phone *Address *Full Name *Relationship *Company *Phone *Address *Previous EmploymentCompany *Phone *Address *Supervisor *Job Title *Starting Salary *Ending Salary *Responsibilities *From *To *Reason for Leaving *May we contact your previous supervisor for a reference? *YesNoCompanyPhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFromToReason for LeavingMay we contact your previous supervisor for a reference?YesNoCompanyPhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFromToReason for LeavingMay we contact your previous supervisor for a reference?YesNoDisclaimer and Signature I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.SignatureStart signing your signature hereYour browser does not support e-Signature field.DateSend Application