| This application
is not valid for employment purposes until
received and screened by LSBC Human Resources
Department. LSBC operates under a Drug-Free
Workplace policy. Prior to employment,
all final candidates must pass a drug screening. Applications
are considered current only for the position(s)
applied or 90 days from date of this application.
We
are an equal opportunity employer, dedicated
to equal access to programs, services and employment.
It is our policy to prohibit discrimination
and provide equal opportunity in employment
for all qualified persons without regard to
their race, color, religion, sex, age, marital
status, national origin, or on the basis of
handicap. LSBC adheres to the Americans with Disability Act and does not discriminate against a qualified individual with a disability because of the existence of the disability.
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PERSONAL
INFORMATION |
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| POSITION DESIRED : 1)
2)
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| If you are hired by LSBC, your hours of work, shift and schedule
may change according to operational requirements.
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CRIMINAL
HISTORY |
| Have you ever been convicted of a crime,
had adjudication withheld, plead no contest (nolo
contendere); or do you have charges pending? (anything
other than minor traffic offenses)
No
Yes - If yes, Date:
State:
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| Charge(s):
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(Please submit a copy of the final disposition papers) |
| A conviction record will not necessarily
be a bar to employment unless applying for a screened
or direct care position. Factors such as age and
time of offense, seriousness and nature of the
violation, and rehabilitation will be taken into
account. |
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EDUCATION
AND TRAINING |
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| Courses, seminars, or training programs you have
completed that are relevant to the position(s)
you seek: |
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SPECIAL SKILLS, CERTIFICATIONS, LICENSURES |
| Special knowledge, skills, and abilities you wish
to be considered. Include equipment or machines
you operate, computer languages, etc. |
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| List fields of work for which you are licensed,
registered, or certified. Please include
license numbers, dates, and sources of issuance. |
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UNEMPLOYMENT |
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REFERENCES |
| List 3 persons NOT related to you, whom you have
known 5 years or longer. |
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Do you share a household with, or are you related
by blood or marriage to anyone currently employed by
LSBC?
No
Yes - If YES, give the names, relationship and department
of all such persons: |
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EMPLOYMENT HISTORY |
| Starting
with your present or last position, list all
employment during at least the past 5 years and
relevant experience beyond 5 years. Please account
for all periods of unemployment for a minimum of
the past 5 years. You may submit a resume as
a supplement but not as a substitute for this section. |
| May we contact you present employer?
Yes
No |
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AGREEMENT |
| PLEASE
READ THE FOLLOWING CAREFULLY
– IMPORTANT INFORMATION -
I understand that any misrepresentation or material
omission made by me on this application (and resume,
if any) will be sufficient cause for cancellation
of this application or immediate discharge from the
employer’s service, whenever discovered.
I understand employment is conditioned on a background
check. I understand and consent to an investigative
background inquiries made on me to possibly include
consumer, criminal, driving and other habits and
general character, performance and experience along
with reasons for termination of past employment from
previous employers. I hereby release from liability
all persons involved in the acts performed in investigating
and evaluating my application.
I consent to the inspection of documents that
verify my education, training, experience, licensure
and/or certification, and liability insurance to
assist in evaluating my qualifications and abilities
to carry out duties for which I am applying.
I understand and agree that nothing contained in
this application, or conveyed during any interview,
is intended to create an employment contract. I
further understand and agree that if hired, my employment
will be “at will” and without fixed term,
and may be terminated at any time, with or without
cause and without prior notice, at the option of
either myself or the Company. No
promises regarding employment have been made to me,
and I understand that no such promise or guarantee
is binding upon the Company unless made in writing
and signed by the Company President.
I understand I will receive a letter should I not
be accepted for this position(s). It will
be necessary to fill out a new application to be
considered for another position(s).
If I am offered employment I agree to submit to
a drug test before starting work. If employed,
I also agree to submit to a medical examination or
drug test at any time deemed appropriate to the Company
and as permitted by law. I consent to such
examinations and tests, and request the examining
doctor disclose to the Company the results (which
shall remain confidential and serrated from my personnel
file) of examination. I understand that my
employment or continued employment, to the extent
permitted by law, is contingent upon satisfactory
medical examinations and drug test.
If I am hired a condition of my employment will
be that I abide by all Company work rules, policies
and procedures including Drug Free Workplace. The
Company retains the right to revise its policies
and procedures, in whole or part, at any time. I
represent and warrant I have read and understand
the above and seek employment under these conditions. |
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