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Application

This institution does not discriminate in hiring or employment on the basis of race, color, religion, sexual orientation, national origin, gender identity, sex, citizenship, age or physical or mental handicap unrelated to the ability to do a job or any other characteristics protected by law. No question on this application is intended to secure information to be used for such discrimination. This application will be given every consideration; however its receipt does not imply that the applicant will be employed.

* denotes required fields
Personal Information

First Name: *
Middle Name:
Last Name: *
Address: *
City / State / Zip Code: *
E-mail Address: *
Home Phone: *
Cell Phone: *
If you cannot be reached at above phone numbers, where may we contact you?
Name of Person/Place:
Phone Number:

Employment Desired

Type of Work Desired: *
Wage Expectation: *
Will you accept employment of: *	Full-time (32-40 hours a week) Part-time (16-32 hours a week) Occasional/PRN (1-16 hours a week)
How did you learn of this opening:
Have we employed you previously? *
If yes, When?
What is your position?
Are you at least 18 years of age? *
Do you have the right to work in the US? *
Have you ever been convicted of a felony? *
If yes, please explain:
Do you have any record of Child or Dependent Adult Abuse? *
If yes, please explain:
During the past seven years, have you ever been denied a driver's license, or convicted of a moving traffic offense, including, but not limited to driving while intoxicated or reckless driving? *

Availability Record

Please indicate days and hours you are available to work (Be Specific.)
Day	From	To
Sunday:	A.M. P.M.	A.M. P.M.
Monday:	A.M. P.M.	A.M. P.M.
Tuesday:	A.M. P.M.	A.M. P.M.
Wednesday:	A.M. P.M.	A.M. P.M.
Thursday:	A.M. P.M.	A.M. P.M.
Friday:	A.M. P.M.	A.M. P.M.
Saturday:	A.M. P.M.	A.M. P.M.
Are you available to work Weekends? *
Are you available to work Holidays? *
Are you available to work Nights? *
When will you be able to begin work? *	(mm/dd/yyyy)

Education

High School
Name of School:
City / State:
Degree, Major or Program:
Number of Years Completed:
Did You Graduate:
College
Name of School:
City / State:
Degree, Major or Program:
Number of Years Completed:
Did You Graduate:
Vocational or Business
Name of School:
City / State:
Degree, Major or Program:
Number of Years Completed:
Did You Graduate:
Nursing Education
Name of School:
City / State:
Degree, Major or Program:
Number of Years Completed:
Did You Graduate:
Laboratory or X-Ray Training
Name of School:
City / State:
Degree, Major or Program:
Number of Years Completed:
Did You Graduate:
Have you ever been in the Armed Forces? *
If yes, what is your present Selective Service Classification?
Are you presently a member of Reserves or National Guard? *
If yes, when is your enlistment up?

Professional Licensure and/or Certifications

Licensure #1
Type:
License or Cert. Number:
State Issued:
Date Issued:	(mm/dd/yyyy)
Expiration Date:	(mm/dd/yyyy)
Licensure #2
Type:
License or Cert. Number:
State Issued:
Date Issued:	(mm/dd/yyyy)
Expiration Date:	(mm/dd/yyyy)
Licensure #3
Type:
License or Cert. Number:
State Issued:
Date Issued:	(mm/dd/yyyy)
Expiration Date:	(mm/dd/yyyy)
Licensure #4
Type:
License or Cert. Number:
State Issued:
Date Issued:	(mm/dd/yyyy)
Expiration Date:	(mm/dd/yyyy)

Employment History

Please give a complete record of all employment. Current or most recent employer should be provided in number one. ALL APPLICANTS MUST COMPLETE THIS SECTION.
Employment #1
Company Name:
Street Address:
City / State:
Phone Number:
Employed From:	(mm/dd/yyyy)
Employed To:	(mm/dd/yyyy)
Manager's Name:
Hourly Wage:
Hours Worked Per Week:
Job Titles/Duties:
Reason for Leaving:
May we contact this employer?
Employment #2
Company Name:
Street Address:
City / State:
Phone Number:
Employed From:	(mm/dd/yyyy)
Employed To:	(mm/dd/yyyy)
Manager's Name:
Hourly Wage:
Hours Worked Per Week:
Job Titles/Duties:
Reason for Leaving:
May we contact this employer?
Employment #3
Company Name:
Street Address:
City / State:
Phone Number:
Employed From:	(mm/dd/yyyy)
Employed To:	(mm/dd/yyyy)
Manager's Name:
Hourly Wage:
Hours Worked Per Week:
Job Titles/Duties:
Reason for Leaving:
May we contact this employer?
Employment #4
Company Name:
Street Address:
City / State:
Phone Number:
Employed From:	(mm/dd/yyyy)
Employed To:	(mm/dd/yyyy)
Manager's Name:
Hourly Wage:
Hours Worked Per Week:
Job Titles/Duties:
Reason for Leaving:
May we contact this employer?
Please explain all periods of unemployment:
If your former employment references, education or military services are under a name other than indicated on front of application, please indicate:
First Name:
Middle Name:
Last Name:

Online Application Terms and Conditions

I certify that the answers and information set out above are true, accurate, and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate, or complete I may not be hired; or if hired, I may be discharged. I authorize Lucas County Health Center (LCHC) to investigate all statements contained in the application for employment to include criminal, child and dependent adult abuse information as well as my character and qualifications. I release LCHC from all liability for acts performed in good faith and without malice in connection with evaluation of my application. I authorize any person, school, current/past employers, and organizations with information regarding my work, educational history or my character, to provide LCHC with all information they request and to cooperate fully with the investigation of my character and qualifications. I also release those persons, schools, current/past employers, and organizations from all liability for providing information in good faith and without malice. I understand that this application is not a contract of employment. I understand that LCHC the use of tobacco products by employees will not be permitted at LCHC or any other facility that is part of LCHC’s operations. This policy will also apply to parking lots, driveways, the LCHC grounds, off-campus employee work sites, and to LCHC-owned vehicles. Employees will be prohibited from using tobacco products during paid working hours while on any LCHC properties including personally owned vehicles while on areas encompassed by the policy. If hired, my employment and compensation can be terminated at will, with or without a showing of cause, and with or without notice by either LCHC or myself. I agree that if employed, I will abide by all policies, procedures, rules, and I also agree to immediately notify LCHC if I should be convicted of a felony, any crime involving dishonesty or a breach of trust while my application is pending, or during my period of employment, if hired. I also understand that if I am offered employment, the offer is conditioned upon receipt of satisfactory employment references, acceptable criminal/abuse background information, and favorable health evaluations which includes a drug test provided by LCHC. I also give permission for a complete post-offer assessment and physical examination, and I consent to the release of any and all medical information, as may be deemed necessary by LCHC in judging my capability to do the work for which I am applying.

Signature and Verification

Please type your name as you would sign it, verifying that all information provided in the application is accurate to the best of your knowledge. You will be asked to provide a real signature on your application if you are brought in for additional interviews.
Digital Signature: *
Verification Code: *	Please enter the letters and numbers you see on the image into the text box below.