Employment Application - Lakeland Surgical & Diagnostic Center

Position Applied For*
Salary Expectations*
Personal Information
Name*
First Name Middle Initial Last Name
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Are you at least 18 years old?*
- Yes
- No
Please state your age for child labor law purposes only.*
Please enter a number less than or equal to 17.
Are there any days, shifts or hours you will not work?*
- Yes
- No
If yes, please explain:*
Are you available for out of town work?*
- Yes
- No
Will you work overtime, if required?*
- Yes
- No
When will you be able to start work?*
MM slash DD slash YYYY
Have you taken any illegal drugs in the last 30 days?*
- Yes
- No
How did you learn of our company?*
If referred, who were you referred by?
Have you ever applied or worked here before?*
- Yes
- No
Please provide the date in which you previously applied.*
MM slash DD slash YYYY
Are you legally authorized to work in the United States?*
- Yes
- No
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)?*
- Yes
- No
Note: The Federal Immigration and Reform and Control Act of 1986 requires that an INS Employment Eligibility Verification Form I-9 be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization for work. This federal requirement must be satisfied as a condition of employment.
Have you been convicted of a felony within the last seven years?*
- Yes
- No
Note: Answering "yes" does not automatically exclude you from consideration for the position. If yes, please explain on the Additional comments section, including the penalty imposed.
Date of Conviction*
MM slash DD slash YYYY
Have you been convicted within the last seven years of misappropriation of funds, embezzlement or other dishonest conduct, an offense involving the use of a weapon, physical assault or other violent crimes?*
- Yes
- No
If yes, please explain on the Additional Comments Section. Note: Answering "yes" does not automatically exclude you from futher consideration for this position.
Have you been a defendant in a civil action for an intentional tort (intentional commission of a wrongful act)?*
- Yes
- No
If yes, include nature of the intentional tort and the disposition of the action in the Additional Comments Section. Note: Answering "yes" does not automatically exclude you from further consideration for this position.
Driving Record
Do you have a valid driver's license?*
- Yes
- No
License No.*
Do you have any tickets?*
- Yes
- No
If yes, please explain.*
Has your license ever been suspended or revoked?*
- Yes
- No
If yes, please explain.*
Do you have any DUI or DWI convictions?*
- Yes
- No
If yes, please state when you were convicted and explain.*
Additional Comments
(Use the space below to supply any additional information relevant to the job applied for.)
Education, Training, And Professional Licensure, Registry and Certification
Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for.*
High School Name & Location Course of Study Years Completed Did you Graduate? Type of Diploma or Degree
*
College/University Name & Location Course of Study Years Completed Did you Graduate? Type of Diploma or Degree
College/University Name & Location Course of Study Years Completed Did you Graduate? Type of Diploma or Degree
*
Graduate/Professional School Name & Location Course of Study Years Completed Did you Graduate? Type of Diploma or Degree
*
Training in Specialty Areas Course of Study Years Completed Did you Graduate? Type of Diploma or Degree
Do you hold professional licensure?*
- Yes
- No
Please list below all states/jurisdications in which you now or have held licensure as a professional.
State/Jurisdiction License No. Type of Licensure
Has your professional license ever been voluntarily, or have you ever been disciplined by, or has your professional license ever been revoked, suspended, reduced, limited, placed on probation, not renewed, or subject to reprimand by a professional board or other regulatory agency?*
- Yes
- No
If yes, please describe in full detail the circumstances and outcome.
CPR Expiration Date*
MM slash DD slash YYYY
ACLS*
- Yes
- No
PALS*
- Yes
- No
Describe any other education, training, skills or certificates you process that are relevant to the position for which you have applied.
Employment History
Starting with current or most recent, list all employers past and present. Include self-employment and summer and part-time jobs. If more space is required, please continue on a separate sheet. You may attach a resume, but you must complete this section of this Application as well. Lakeland Surgical & Diagnostic Center, L.L.P. verifies all information disclosed in this section.
Company Name*
Company Address*
Street Address Address Line 2 City State ZIP Code
Company Phone*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Name of Supervisor*
May we contact?*
- Yes
- No
Starting Rate of Pay*
Ending Rate of Pay*
State job titles and describe job duties*
Reason for leaving*
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Name of Supervisor
May we contact?
- Yes
- No
Starting Rate of Pay
Ending Rate of Pay
State job titles and describe job duties
Reason for leaving
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Name of Supervisor
May we contact?
- Yes
- No
Starting Rate of Pay
Ending Rate of Pay
State job titles and describe job duties
Reason for leaving
Company Name
Company Address
Street Address Address Line 2 City State ZIP Code
Company Phone
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Name of Supervisor
May we contact?
- Yes
- No
Starting Rate of Pay
Ending Rate of Pay
State job titles and describe job duties
Reason for leaving
Please explain any gaps in your employment history.*
Have you ever been discharged or forced to resign?*
- Yes
- No
If yes, please explain.*
Did you receive any discipline in the last 12 months of active employment?*
- Yes
- No
If yes, please explain.*
Were you given a performance evaluation within the last 12 months of active employment?*
- Yes
- No
If yes, what was the range of scores used and what was your score?*
Have you signed any non-compete or non-solicit agreement with any other employer that might restrict you from working for Lakeland Surgical & Diagnostic Center, L.L.P.?*
- Yes
- No
You may be required to furnish a copy of the agreement.
If yes, please explain.*
References
List current and former co-workers, and/or professional acquaintances not related to you (other than those persons listed previously who can provide first hand knowledge of your qualifications and abilities).*
Name Relationship to you Occupation and Title Phone No. Years Known
Military
Have you served in the Military?*
- Yes
- No
Branch of Service
Number of Years/Months of Service
Rank at Discharge
Discharge Date
MM slash DD slash YYYY
Reason for leaving
Describe any military skills, training or experience you believe are relevant to the job applied for.
Resume
Paste Resume Below*
Applicant’s Acknowledgement
I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers in any application document will disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application document will cause for my dismissal at any time without prior notice.

I understand that, if employed, my employment is not for a specific term and may be terminated by me or my Employer with or without notice or cause at any time. I further understand that no oral promise, Employer(s) policy, custom, business practice (including the Employee Handbook or any personal materials) constitute an employment contract or modification of at will employment relationship between me and the Employer.

I understand that applicants for certain positions may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job related tests; take a driver’s examination; submit to a background investigation; take a pre-employment drug and nicotine test. If I am offered employment or start work before any of the required tests are completed, my employment is contingent on a satisfactory result on all required tests. I authorize Lakeland Surgical & Diagnostic Center, L.L.P. and its clients to release the results of the background checks (if any) and my pre-employment drug/alcohol and nicotine test (if any), any information on this application and any relevant information about me to each other and release Lakeland Surgical & Diagnostic Center, L.L.P. and its clients from any and all claims related to the lawful release of this information. I further authorize the release of any background check results of any drug/alcohol and nicotine test to any state or federal authority requesting such information and in response to valid subpoena or other legal document.

In compliance with the federal Immigration Reform & Control Act, I agree, if hired, to provide within three (3) business days from the date that my employment begins, proof of my identity and eligibility for employment in the United States.

Further, I understand that, if I am employed, all materials, equipment and space allocated to me for the discharge of my duties may be inspected as deemed necessary by Lakeland Surgical & Diagnostic Center, L.L.P. at its sole discretion.
*
- I have read and understand this agreement
Phone
This field is for validation purposes and should be left unchanged.

State/Jurisdiction	License No.	Type of Licensure

Name	Relationship to you	Occupation and Title	Phone No.	Years Known

Personal Information

Driving Record

Additional Comments

Education, Training, And Professional Licensure, Registry and Certification

Employment History

References

Military

Resume

Applicant’s Acknowledgement