Employment Application - Step 1: Personal Info

Application Form

All bolded fields are mandatory. You must press the Submit button below to forward your application.
Please fill out this form even if you have already sent us a resume.

Name		Address
Last First Middle Other Names Under Which You Have Worked		Home & Street City State Zip Code Phone# Social Security # Alt/Cellular # Email
Applications for specific open positions will have first consideration. Position Desired 1 2 Job Type(s) Full-Time Part-Time PRN (as needed) Temporary Date Available For Work Days and times NOT Available for Work Please, List your Salary Expectations From To Do you have any relatives who work for LMH? Yes No If Yes, please list name & relationship Have you ever worked for Lawrence Memorial Hospital? Yes No If Yes, indicate date, description of duties and name under which you were employed. How did you hear about this job? - Select - Newspaper Website Word of Mouth Job Fair Referred by a LMH Associate Other
In order to provide the best patient care, we need to ask you the following questions:
Have you ever been convicted of a felony? Yes No Have you ever been convicted of a Healthcare related crime? Yes No If Yes, Explain Are you over the age of 18? Yes No Are you legally entitled to work in the U.S. for any employer and could you provide proof upon offer of employment? Yes No