EmailMe Form - Lake Country Home Care, LLC Employment Application

Date Time

MM / DD / YYYY

Name

Prefix First MI Last Suffix

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

How long have you lived at this address?

Social Security Number

Do not use dashes.

Phone

### - ### - ####

Email

If under 18, please list age.

Days/Hours Available to Work

No Preference
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Available Start Date

Driver's License

Number
State of Issuance
Expiration Date

Please state any pertinent educational experience you may have:

Will you agree to a background study in accordance with State/Federal regulations?

Yes

No

Have you had a Mantoux test in the last year?

Yes

No

Date of last Mantoux test:

Reference #1

Name
Position
Company
Address
Telephone

Reference #2

Name
Position
Company
Address
Telephone

Work Experience - Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Name of Employer
Street Address
City, State, Zip Code
Phone
Your Job Title
Name of Supervisor
Dates of Employment
Reason for Leaving (be specific)

List duties performed, skills used or learned, advancements or promotions while you worked at this company.

Work Experience - Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Name of Employer
Street Address
City, State, Zip Code
Phone
Your Job Title
Name of Supervisor
Dates of Employment
Reason for Leaving (be specific)

List duties performed, skills used or learned, advancements or promotions while you worked at this company.

Work Experience - Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Name of Employer
Street Address
City, State, Zip Code
Phone
Your Job Title
Name of Supervisor
Dates of Employment
Reason for Leaving (be specific)

List duties performed, skills used or learned, advancements or promotions while you worked at this company.

I authorize LCHC to contact any of my previous or current employers for references.

Yes

No

Please upload your resume.