Application for Employment

Lakeside Health System (LHS) considers all candidates for employment without regard to race, creed, color, gender, national origin, age, marital status, sexual orientation, disability, citizenship, criminal record, religion and military status.

Instructions

Drug screening is conducted as part of new-hire physicals. Lakeside Health System is a smoke-free organization and as such smoking is prohibited in buildings, on the grounds and in vehicles parked on LHS lots.

  1. Complete all sections of the application.
  2. Please allow a minimum of two weeks for an application to be reviewed after it is submitted. Applicants will be contacted for interviews if it’s determined their qualifications and experience are appropriate matches to the job requirements.
  3. All applications are retained on file for one year from the date of submission.
  4. If you are not selected to fill the position originally applied for and you become aware of another similar opportunity during the period your application is active, you may contact the LHS recruiter (585-395-6080) and request consideration for the new opening.
Personal Information
Date:
SS# (last four): XXX - XX -
First Name:
Middle Initial:
Last Name:
Address:

City:
State: Zip:
Telephone:
Mobile Telephone:
How did you hear about the position:
Are you at least 18 years of age: yes no - If no, indicate your age:
Are you related to a current LHS employee? yes no - If yes, indicate their name:
Are you a citizen of the United States?

yes no

If no, are you legally permitted to work in the U.S.? yes no

Have you been previously employed by LHS?

yes no
If yes, what dates did you work?

If previously employed by LHS, under what name were you employed:
If previously employed by LHS, where did you work?
List all other names used at previous employers:
Are you currently employed?

yes no

If yes, may we contact your present employer? yes no

Have you ever been convicted of a misdemeanor or felony?

yes no

(Before answering, please review the explanation below. If, in light of the relevant explanation, your answer is “Yes”, please explain in the space provided. A conviction will not automatically disqualify you from employment and your response will only be used in connection with evaluation of your application.)
  Explanation Regarding Criminal Convictions: Do not respond “Yes” for a conviction that has been judicially annulled, expunged, sealed, or statutorily eradicated. You are not required to list youthful offender adjudications or convictions sealed pursuant to New York law. You need not disclose any arrest, detention or disposition regarding any violation of law in which no conviction resulted.
Job Interest
Position Desired:
Available Start Date:
Wage/Salary Requirement:
Employment Desired:
Availability (check all that apply): Day Shift Evening Shift Night Shift Weekends
Overtime Holidays.

yes no

Are you able to perform the essential duties of the job for which you are applying with or without reasonable accommodation?

(If you are unsure of the specific job duties required please contact the Human Resource office.)
Education & Training

Select the highest grade/year completed:

  School Name Location Classes/Major Degree Earned
HS
College
Other

 

List any special skills or training:

List any professional certificates or licenses held past or present including CNA (give number, expiration date, state):

Has your license or certification in any state been restricted, suspended, or revoked? yes no
Is any disciplinary action currently pending against your certification or license in any state? yes no
Are you currently listed on the Office of the Inspector General (OIG) and/or the General Services Administration (GSA) exclusion from federal health care programs, and/or the NYS Office of Medicaid Inspector General exclusion list (OMIG)?

OIG:     yes no

GSA:    yes no

OMIG:   yes no

 

If you’ve been issued a National Provider Identifier (NPI) or Taxonomy Code(s) please list them here:

NURSING APPLICANTS ONLY

Have you had special training in:

Employment Experience

Indicate below all your employers from the last ten (10) years starting with your current or most recent job.

Employment Exp. 1
Employer:
Address:
Phone:
Dates Employed:
Position(s) Held:
Supervisor Name:
Wage:
Reason for leaving:
Employment Exp. 2
Employer:
Address:
Phone:
Dates Employed:
Position(s) Held:
Supervisor Name:
Wage:
Reason for leaving:
Employment Exp. 3
Employer:
Address:
Phone:
Dates Employed:
Position(s) Held:
Supervisor Name:
Wage:
Reason for leaving:
References

Provide three (3) professional references who are not related to you. If you are unable to list three professional references, you may substitute personal and/or character references.

  NAME Address/Phone Occupation
1)
2)
3)

Please provide any additional information that you feel may be helpful in the consideration of your application:

Applicant's Statement

I understand this application is not a contract of employment. In the event I become employed by Lakeside Health System (LHS) I understand my employment is at-will and is not for a specified or definite term and that I may be discharged or I may resign at any time for any reason, with or without cause.

I certify that all answers provided herein are true and complete to the best of my knowledge. I understand the provision of false or misleading information or the omission of information on this application or given during an interview process could result in the rejection of my application or my termination if I become employed.

LHS, and/or its authorized agents may investigate any or all information I have provided on my application and/or resume including criminal convictions, education, and employment experience information. Such verification may take the form of an investigative consumer report whereby information is obtained through personal interviews with those able to verify the information I have provided as well as my character and general reputation. I will sign a consent form authorizing such verification, and my authorization will be valid until such time as I inform LHS in writing.

By submitting this form I authorize all former schools, employers and other references to provide information and opinion to (LHS) relevant to my experience, character, etc. This includes dates of attendance, degrees earned, dates of employment, wages, reasons for leaving employment and any other information regarding my performance that may be requested by LHS. I release LHS and all parties providing information from any liability or claims for damages including libel, slander, and invasion of privacy that may result from the disclosure and use of this information.

I understand my employment at LHS is subject to verification of my proof of eligibility to work in the United States, the successful passing of a physical examination and drug test, the favorable result of a criminal background check and where applicable, confirmation of appropriate credentialing.

If employed, I understand I am required to abide by all rules and policies of Lakeside Health System.

 

My typed name below shall have the same force and effect as my written signature.

Candidate's/Applicant's Signature: Date:

Voluntary Self-Identification Data Form

Lakeside Health System has adopted a diversity initiative with regard to employment opportunities for qualified individuals. Please assist us in implementing this initiative by providing the information requested below. Providing this information is voluntary and providing or refusing to provide it will not subject you to any adverse treatment. The information you provide will only be used for equal employment/affirmative action recordkeeping and reporting. The information you provide is confidential and not available to hiring managers. Name and date are required however you can elect not to self-identify. Return this with your application.

Please check here if you choose not to self-identify:

GENDER:
Race/ethnicity:  
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above six ethnic categories.
Veteran Status:

 

   
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