Employment Application

Employment Application
Medical Volunteer Information
Name*

First NameMiddle NameLast Name
Last 4 digits of social security number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Position(s) applied for or type of work desired:*
Full-timePart-timeTemporary
Date you will be available to start work:*

MonthDayYear
Date
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, please explain (a conviction will not automatically bar employment):*
How were you referred to us?*
Please provide all employment information for your last four employers starting with the most recent.
Employer
Position Held
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Immediate Supervisor and Title
Dates Employed (from)

MonthDayYear
Date
Dates Employed (to)

MonthDayYear
Date (If you are currently employed here, please put today's date.)
YesNo
Wages/Salary
Job Summary
Reason for Leaving
Employer
Position Held
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Immediate Supervisor and Title
Dates Employed (from)

MonthDayYear
Date
Dates Employed (to)

MonthDayYear
Date (If you are currently employed here, please put today's date.)
YesNo
Wages/Salary
Job Summary
Reason for Leaving
Employer
Position Held
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Immediate Supervisor and Title
Dates Employed (from)

MonthDayYear
Date
Dates Employed (to)

MonthDayYear
Date (If you are currently employed here, please put today's date.)
YesNo
Wages/Salary
Job Summary
Reason for Leaving
Employer
Position Held
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Immediate Supervisor and Title
Dates Employed (from)

MonthDayYear
Date
Dates Employed (to)

MonthDayYear
Date (If you are currently employed here, please put today's date.)
YesNo
Wages/Salary
Job Summary
Reason for Leaving
Other Skills & Qualifications
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:
Heading

Educational History: List university/college name and location, years completed/graduation date, course of study, and any degrees earned:
University/College
Technical Training
Other
References
List three (3) professional references with names, telephone numbers, and years known (do not include relatives or friends):
Emergency Contact Name & Phone Number:
Relationship to Emergency Contact Person:
Resume*

Cancelof
I hereby authorize Beach House, Inc. dba Leading Families Home to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability Beach House, Inc. dba Leading Families Home and its representatives for seeking, gathering, and using information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I hereby authorize Beach House, Inc. dba Leading Families Home to conduct a criminal background check on me as a condition of being considered for employment, and I unconditionally release Beach House, Inc. dba Leading Families Home from any and all possible claims for liability arising from, or in any manner related to such investigation.
Signature

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Date

MonthDayYear
Date
Like most American employers, LFH does not offer employees formal contracts of employment. Rather all employment is “at will,” meaning that either you or the Company may end your employment at any time for any reason.

Beach House, Inc. dba Leading Families Home is an equal employment opportunity employer that selects the individual who is the best match for a position based on job-related qualifications, without regard to race, color, creed, sex, national origin, religion, sexual preference, age, disability, genetic information, or other protected group status.
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Employment Application

Medical Volunteer Information

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