Lakeside Pediatrics Employment Application

Date

Name

First NameLast Name

Date of birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact number

Please enter a valid phone number.Format: (000) 000-0000.

Do you have the right to work in the United States?

YesNo

Position(s) applied for

Do you Prefer:

Full-TimePart- time

Desired Rate of Pay

Do you own a car

YesNo

Distance willing to travel

Do you currently have a valid Drivers License

YesNo

Are you at least 18 years of age?

YesNo

What is the earliest date you are available for work?

Date

Please specify the time and days you are available for work

Rows	From:	To:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Check highest level completed:

Education

Rows	Location	Date of attendance	Graduated? (Y/N)	Type of Degree
High School
College
Graduate of Professional school
Vocational Technical School

List specific courses, workshops or training you have had that are related to the position for which you are applying.

Please check the following experiences you have working in this field:

Skills: Check the following skills/certifications you have

Have you lived in Idaho for the past 5 years?

YesNo

Are you related, by blood or marriage, to any person now working at Lakeside Peds? (Y/N) If yes, please give name, and relationship to you and the department where employed.

Have you worked under any other name? (Y/ N) If yes, please give list.

Have you ever worked for another medical office not listed in your work history?

YesNo

Have you ever been dismissed or requested resignation due to abuse, neglect, or any act of aggression?

yesNo

Have you ever been convicted of a felony?

YesNo

Other than minor traffic violations, have you ever been convicted of a misdemeanor? (Y/N) If yes, (to a felony or misdemeanor), please explain when, where, and disposition of case. NOTE: The existence of a criminal record does not automatically eliminate you from employment considerations.

Have you ever held a position of trust (Handling money or confidential material)?

YesNo

Have you ever been reported to the ODODD Abuse registry?

YesNo

Have you ever been reported to the ODH Nurse Aide Registry?

YesNo

Reference

Rows	Name	Year known	Organization/Title	Contact Information
Person 1
Person 2
Person 3

Statements of Attestation:
Lakeside Pediatric & Adolescent Medicine PLLC (LSP) is an equal opportunity employer and selects the best matched individual for the job based upon job related qualifications regardless of race, color, creed, sex, age, national origin, handicap, or other protected group under state, federal equal opportunity laws.

Please sign below this statement. Your signature is indicative of understanding and agreement.

I attest I have never been convicted of or pled guilty to any offenses that would disqualify me from employment with Right
at Home. (See attached list for disqualifying offenses)
LSP intends to check and hold me responsible for the accuracy of the statements made on this application. Any material
misrepresentation or deliberate omission of a fact in the application may be justification for refusal of, or if employed, termination
from employment.
LSP will make a thorough investigation of my entire work history and may verify all data given in my application for
employment, related papers, and/or oral interviews. I authorize such investigation and the exchange of information requested by
Right at Home and I release from liability any person giving or receiving any such information. I understand that falsification of
data so given or derogatory information discovered as a result of this investigation may prevent my being hired or, if hired may
subject me to immediate dismissal.
To submit to drug screening by a qualified physician at the discretion of my employer. I understand that submitting to a
drug screen may be required as part of the pre-employment process and can be given at any time during my employment. I do
understand that failure to submit to any drug screen is cause for immediate dismissal and a negative result can result in disciplinary
action including termination.
That, although management makes every effort to accommodate individual preferences and religious beliefs, business
needs, at times, may require overtime, shift work, rotating work schedules and locations, holiday work or a work schedule other
than Monday through Friday, and I accept these as conditions of my continuing employment.
This is an application for employment and in no way an employment contract is offered or implied.
If I become employed, such employment is for no definite period of time and that LSP may change wages, benefits and
conditions of employment at any time.
If I become employed or receive a job status change after employment, I will serve a 90-day probationary employment
period.
If hired, you will be asked to sign a confidentiality agreement and a non-compete agreement under company policy.
If considered a candidate for employment, I understand I may be asked to provide the following: Proof of Residency for the
past 5 years and a notarized statement regarding my residency status
I have read, understand, and agree to the above conditions.

Signature

Date

Please upload your resume/CV here

Form

Education:

Experience