Careers - Lakeside Home Care

Name

First

Last

Street Address

Phone

Email

SSN

Position Applying For

Desired Salary

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?

Dates Attended

Did you graduate?

Yes

No

Diploma

Yes

No

College Attended

Dates Attended

Did you graduate?

Yes

No

Degree

Yes

No

Reference #1 Full Name

Reference #1 Relationship

Reference #1 Phone

Reference #1 Company

Reference #1 Address

Reference #2 Full name

Reference #2 Relationship

Reference #2 Phone

Reference #2 Company

Reference #2 Address

Reference #3 Full Name

Reference #3 Relationship

Reference #3 Phone

Reference #3 Company

Reference #3 Address

Previous Employer #1 Company

Previous Employer #1 Address

Previous Employer #1 Phone

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 Address

Previous Employer #2 Phone

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 Address

Previous Employer #3 Phone

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

First

Last

Emergency Contact Phone Number

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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