LaSalle Bristol Job Application First Name Last Name Your Email Job Applied For Date of Application Street Address City/State Zip Code Home Phone Mobile Phone Date you will be available for work? Drivers License Number & State Issued Are you 18 years of age or older?yesno Have you ever been employed here before? yesno Can you meet attendance requirements of the position? yesno Are you legally eligible to work in this country? (Proof of US Citizenship or immigration status will be required upon employment)yesno Type of employment desired? Full TimePart TimeTemporarySeasonalEducational/Co-Op Have you been convicted of a felony in the past 7 years? yesno (Such a conviction may be relevant if job related, but does not bar you from employment. The inquiry as to whether you have been convicted of a crime does not require you to disclose, verbally or in writing, any record of a conviction or arrest that has been expunged or sealed.) If you answered yes, please explain. Education High School Graduate? YesNo College Graduate? YesNo Trade/Business School Graduate?YesNo Employment History List your last 4 employers or volunteer activities. Start with the most recent, include any military experience. Reference 1 Name of Employer Contact phone number Your immediate supervisor City/State Date Worked From: Date Worked To: Job title or position Reason for leaving? Short description of your responsibilities Reference 2 Name of Employer Contact phone number Your immediate supervisor City/State Date Worked From: Date Worked To: Job title or position Reason for leaving? Short description of your responsibilities Reference 3 Name of Employer Contact phone number Your immediate supervisor City/State Date Worked From: Date Worked To: Job title or position Reason for leaving? Short description of your responsibilities Reference 4 Name of Employer Contact phone number Your immediate supervisor City/State Date Worked From: Date Worked To: Job title or position Reason for leaving? Short description of your responsibilities Résumé Upload I authorize investigation of all statements contained in this application. I understand misrepresentation or omission of facts called for is cause for my application not being considered, or if employed, termination. Further, I understand and agree my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice. It is the policy of LaSalle Bristol to include a drug test and background check as a condition of employment. I hereby authorize the clinic specified by LaSalle Bristol to conduct a drug test with a urine specimen furnished freely and voluntarily by me. Should the results of the test indicate the presence of drugs, my application for employment will be nullified. I hereby release all parties, including but not limited to LaSalle Bristol, personal references, and previous employers, from any and all liability for any injury or damage that may result from their furnishing information to LaSalle Bristol concerning me or any other action LaSalle Bristol takes on the basis of such information. I understand any offer of employment to me by LaSalle Bristol is contingent upon my ability to produce the required documentation within the time period required by law. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. LaSalle Bristol participates in E-Verify. We will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee’s Form I-9 to confirm work authorization.
