LHC Application for Employment

References
REFERENCE 1
Name:*

First NameLast Name
Relationship:*
Company:*
Telephone:*
Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
REFERENCE 2
Name:*

First NameLast Name
Relationship:*
Company:*
Telephone:*
Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
REFERENCE 3
Name:*

First NameLast Name
Relationship:*
Company:*
Telephone:*
Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Employment History
Name of Company:
Job Title:
Phone Number:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor:
Starting Salary:
Ending Salary:
Responsibilities:
Date Position Started:

MonthDayYear
Date
YesNo
Date Position Ended:

MonthDayYear
Date
Reason For Leaving:
YesNo

Employment History

Continued
Name of Company:
Job Title:
Phone Number:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor:
Starting Salary:
Ending Salary:
Responsibilities:
Date Position Started:

MonthDayYear
Date
YesNo
Date Position Ended:

MonthDayYear
Date
Reason For Leaving:
YesNo

Employment History

Continued
Name of Company:
Job Title:
Phone Number:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor:
Starting Salary:
Ending Salary:
Responsibilities:
Date Position Started:

MonthDayYear
Date
YesNo
Date Position Ended:

MonthDayYear
Date
Reason For Leaving:
YesNo

Military Service

Continued
YesNo
Branch of Service:
Rank at Discharge:
Served From:

MonthDayYear
Date
To:

MonthDayYear
Date
Type of Discharge:
If other than honorable, please explain:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature:*
Today's Date:*

Lamb Healthcare Center
1500 South Sunset
Littlefield, TX 79339
P: 806.385.6411
F: 806.385.3998
ADDITIONAL INFORMATION
YesNo
A conviction may be relevant if job related, but does not necessarily bar you from employment.
PLEASE READ EACH OF THE FOLLOWING STATEMENTS:

I certify that all answers or statements I have made on this application or on my resume or other supplementary materials are true and correct without omissions. I acknowledge that any false statement or misrepresentation on my application or supplementary materials will be cause for refusal to hire or for immediate dismissal from employment at any time during period of employment. I hereby authorize Lamb Healthcare Center to make any investigation of my background deemed necessary.
Initial:*
I further authorize the companies and school previously listed, unless otherwise indicated, to give all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties form all liability for any damage that may result from furnishings such information to this facility. Offers of employment are conditioned on the receipt of satisfactory responses to reference requests.
Initial:*
I understand and that my employment is pending satisfactory results of a post offer, drug test, background investigation, and satisfactory proof of identity and legal authority to work in the United States.
Initial:*
In consideration of my employment, I agree to conform to the rules and standards of Lamb Healthcare Center as amended form time to time and agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice at any time, either at my option or at the option of the facility. I understand that no employee or representative of the facility other than its Present/CEO has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implies agreement for employment for any specified period of time or to make any express or implies agreement contrary to the forgoing. Further the President/CEO of the facility may not alter the “at will” nature of the employment relationship or enter into any employment agreement for a specified time unless the President/CEO and both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this shall constitute a final and fully binding interrogated agreement with respect to the “at-will” nature of employment relationship or enter into any employment agreement for a specified time unless the President/CEO and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this shall constitute a final and fully binding interrogated agreement with respect to the “at-will” nature of my employment relationship and that there are no oral or collateral agreements regarding this issue.
Initial:*
Signature of Applicant:*
Today's Date:*

Notice and Consent to Background Investigation
NOTICE:

Lamb Healthcare Center intends to conduct an investigation, and/or obtain from a consumer reporting information concerning your character, general reputation (including criminal records), personal characteristics, and mode of living for the purpose of determining your eligibility for employment or continued employment. By your signature below, you are affirmatively authorizing Lamb Healthcare Center to request and use you report for employment purposes.
CONSENT:

I hereby authorize Lamb Healthcare Center to request and obtain a report on me as described above for purposes of evaluating my qualifications for employment and/or continued employment. I also understand that if a report from a consumer reporting agency is the basis for an adverse employment action, I can be furnished a copy of the report and such additional information as may be required by the law. This information shall remain valid until I furnish Lamb Healthcare Center a written revocation.
Signature of Applicant:*
Printed Name of Applicant:*
Today's Date:*

DPS Computerized Criminal History (CCH) Verification

(Agency Copy)
I, {fullName11}, have been notified that a computerized criminal history (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and date of birth (DOB) information I supply.

Because the name based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization (as listed below) conducting the criminal history check is not allowed to discuss any information obtained using this method, therefore the agency may offer the opportunity to have a fingerprint search performed to clear any misidentification based on the name search, if the search provides a criminal report I know could not be mine.

For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety (AFIS) automated fingerprint identification system). I have been made aware that in order to complete this process I must have the correct fingerprinting (FAST) form from this agency, make an online appointment, submit a full and complete set of my fingerprints, and pay a fee of $9.95 to the fingerprinting services company, L1 Enrollment Services.

Once this process is complete and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.
(This copy must remain on file by your agency. Required for future DPS Audits)
Signature of Applicant:*
Lamb Healthcare Center
NAME OF AGENCY
Today's Date:*
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Employment History

Employment History

Employment History

Military Service

Notice and Consent to Background Investigation

DPS Computerized Criminal History (CCH) Verification