Lakeland Surgical & Diagnostic Center - Employment Application

If You Would Prefer to Fill Out and Mail in an
Employment Application, Click Here to Download a Copy.

Click Here for a Copy of Our Web Site Agreement.

* Position Applied For:

* Date:

ex. MM/DD/YYYY

* Salary Expectations:

* First Name:

* Middle Initial:

* Last Name:

* SSN:

ex. 123-45-7890

* Street Address:

* City:

State:

* Zip:

* Phone:

ex. (123) 456 - 7890

YesNo

Are you at least 18 years old?
If not, state your age for child labor law purposes only:

YesNo

Are there any days, shifts or hours you will not work?

If yes, please explain:

YesNo

Are you available for out of town work?

YesNo

Will you work overtime, if required?

* When will you be able to start work?

ex. MM/DD

YesNo

Have you taken any illegal drugs in the last 30 days?

* How did you learn of our company?

If referred, who were you referred by?

YesNo

Have you ever applied or worked here before?
If yes, provide date: ex. MM/DD/YYYY

YesNo

Are you legally authorized to work in the United States?

YesNo

Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)?

Note: The Fedreal 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.

YesNo

Have you ever be convicted of a felony within the last seven years?
Date of Conviction: ex. MM/DD/YYYY

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.

YesNo

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? If yes, please explain on the Additional Comments Section. Note: Answering "yes" does not automatically exclude you from futher consideration for this position.

YesNo

Have you been a defendant in a civil action for an intentional tort (intentional commission of a wrongful act)? 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 futher consideration for this position.

(Answer only if driving is a requirement of the job for which you are applying)

YesNo

Do you have a valid drivers license?
License No.

YesNo

Do you have any tickets?
If yes, please explain:

YesNo

Has you license ever been suspended or revoked?
If yes, please explain:

YesNo

Do you have any DUI or DWI convictions?
If yes, please state when you were convicted and explain:

(Use the space below to supply any additional information relevant to the job applied for)

0/650

Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:

School	Name and Location of School	Course of Study	No. of Years Completed	Did you Graduate?	Type of Diploma or Degree
High School*				YesNo
College or University				YesNo
College or University				YesNo
Graduate or Professional School				YesNo
Training in Speciality Areas				YesNo

YesNo

Do you hold professional licensure?
If yes, please list below all states/jurisdications in which you now or have held licensure as a professional:

State/Jurisdiction	License No.	Type of Licensure

YesNo

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?

If yes, please describe in full detail the circumstances and outcome:

CPR Expiration Date:

ex. MM/DD/YYYY

YesNo

ACLS

YesNo

PALS

Describe any other education, training, skills or certificates you process which are relevant to the position for which you have applied:

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:
Address:
Phone:	ex. (123) 456 - 7890
Dates Employed
From:	ex. MM/DD/YYYY
To:	ex. MM/DD/YYYY
Name of Supervisor:
YesNo	May we contact?
Rate of pay
Start:
Last:
State job titles and describe job duties:

Reason for leaving:

Company Name:
Address:
Phone:	ex. (123) 456 - 7890
Dates Employed
From:	ex. MM/DD/YYYY
To:	ex. MM/DD/YYYY
Name of Supervisor:
YesNo	May we contact?
Rate of pay
Start:
Last:
State job titles and describe job duties:

Reason for leaving:

Company Name:
Address:
Phone:	ex. (123) 456 - 7890
Dates Employed
From:	ex. MM/DD/YYYY
To:	ex. MM/DD/YYYY
Name of Supervisor:
YesNo	May we contact?
Rate of pay
Start:
Last:
State job titles and describe job duties:

Reason for leaving:

Company Name:
Address:
Phone:	ex. (123) 456 - 7890
Dates Employed
From:	ex. MM/DD/YYYY
To:	ex. MM/DD/YYYY
Name of Supervisor:
YesNo	May we contact?
Rate of pay
Start:
Last:
State job titles and describe job duties:

Reason for leaving:

Please explain any gaps in your employment history:

YesNo

Have you ever been discharged or forced to resign?

If yes, please explain:

YesNo

Did you recieve any discipline in the last 12 months of active employment?

If yes, please explain:

YesNo

Were you given a performance evaluation within the last 12 months of active employment?

If yes, what was the range of scores used and what was your score?

YesNo

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.?

If yes, please explain:

(You may be required to furnish a copy of the agreement)

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. ex. (123) 456 - 7890	Years Known

(Complete only if you served in the military)

Branch of Service:

Number of Years/Months of Service:

Rank at Discharge:

Discharge Date:

ex. MM/DD/YYYY

Reason for leaving:

Describe any military skills, training or experiance you believe are relevant to the job applied for:

* Paste Resume Below:

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 modifi cation of at will employment relationship between me and the Employer.

I understand that applicats 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 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 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 od any background check results of any drug/alcohol test to any state or federal authority requesting such information and in response to valid subpeona 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