It is our policy to comply with all state and federal laws prohibiting discrimination in employment based on race, age, color, religion, national origin, or other protected classification.

Lakeview Christian Home Employment Application
NAME:
**Last
**First
**Middle
ADDRESS:
**Street
**City
**State
**Zip
GENERAL:
**Phone
Email
Are you over 17 years old? Yes
No  
Are you authorized to work in the U.S. on an
unrestricted basis?		 Yes
No  
Have you worked for Lakeview Christian Home Before? Yes
No  
Position(s) Applying for?
(Enter "CNA Class" here if applying for the free class)		 1
2
Wage or salary desired?
When can you start?
How did you learn of this Opening? Radio
Newspaper
Internet
Television
Friend
Other
Are there any hours, shifts, days, or holidays you cannot
or will not work?
Shift Prefered 6am-2pm
2pm-10pm
10pm-6am
Do you want to work Part-Time, Full-Time, or PRN
Are you willing to work overtime as required? Yes
No  
Do you have a physical or medical condition which
would limit your capacity for the job?		 Yes
No  
If yes, what can be done to accomodate your limitation?
Have you ever been convicted of a crime?
(Conviction will not necessarily disqualify an applicant)		 Yes
No  
If yes, describe conditions?
EDUCATION:
Please input the following information into their correspoding boxes
    1. Name of School
    2. Location
    3. Major
    4. Diploma/Degree
High School 1
2
3
4
College/University 1
2
3
4
College/Univeristy 1
2
3
4
Other Training/Education 1
2
3
4
WORK HISTORY:
May we contact your present employer? Yes
No  
Most Recent Employer
Company
Address
Telephone
Name and Title of Supervisor
Start/End Date to
Starting Position
Starting Salary per
Position on Leaving
Salary on Leaving per
Description of Duties
Reason for Leaving
Previous Employer 1
Company
Address
Telephone
Name and Title of Supervisor
Start/End Date to
Starting Position
Starting Salary per
Position on Leaving
Salary on Leaving per
Description of Duties
Reason for Leaving
Previous Employer 2
Company
Address
Telephone
Name and Title of Supervisor
Start/End Date to
Starting Position
Starting Salary per
Position on Leaving
Salary on Leaving per
Description of Duties
Reason for Leaving
Previous Employer 3
Company
Address
Telephone
Name and Title of Supervisor
Start/End Date to
Starting Position
Starting Salary per
Position on Leaving
Salary on Leaving per
Description of Duties
Reason for Leaving

APPLICANT'S CERTIFICATION AND AGREEMENT

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statments may result in dismissal. I authorize the company to make an invesigation of any kind the fact set forth in this application.

I understand that employment at this company is "at will", which means that either I or the company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment is continued on that basis. I understan that no supervisor, manager or administrator, exept for the Board of Directors, has authority to alter the foregoing.

I understand that pevious employers and references will be contacted.

Please note this application is time stamped upon submittal and you may be asked to sign a copy of the application if selected for an interview.