Housekeeper

General Information
Legal Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code

Are you authorized to work in the United States?*
Are you 18 years of age or older?*
Have you ever been convicted of a Felony or Misdemeanor that would prohibit you from working in a Long Term Care, Assisted Living, or Personal Care Facility?*
*Answering yes will not necessarily disqualify you from consideration for employment. Please Provide Details of the conviction(s) including date, conviction, and in what state it occurred:
Have you ever been dismissed from employment due to abuse of healthcare clients and / or residents?*
*If yes, please explain:

Date Available to Start*
Availability*
Please select all that apply.
Please list the days and times you cannot work.*
Are you able to perform the essential functions of the position(s) for which you are applying with or without reasonable accommodations?*
If no, please explain:
Have you ever worked for LECOM, Millcreek Community Hospital, LECOM Wellness Center, or LECOM Senior Living Center previously?*
If yes, when and what position?
Please provide three references who can evaluate you in your professional capacity.
References
Please provide up to three references who can evaluate you in your professional capacity.
Name Employer Position Telephone

High School Education
High School Education*
High School Name High School Address High School Major/Subject High School Graduation Year
Did you graduate high school?*
College Education
College Education
College Name College Address College Major/Subject College Graduation Year
Did you graduate college?
Graduate Education
Graduate School Education
Graduate School Name Graduate School Address Graduate School Major/Subject Graduate School Graduation Year
Did you graduate from your graduate school program?
Technical or Professional Education
Technical or Professional Education
Technical or Professional School Name Technical or Professional School Address Technical or Professional School Major/Subject Technical or Professional School Graduation Year
Did you graduate from your technical or professional school program?
Other Education
Do you have any other education you would like to mention?
Other Education
School Name School Address School Major/Subject Year of Graduation
Did you graduate from this program?
Professional Licenses or Certifications (Including Nursing and CPR).
Licenses or Certifications
You may add up to ten licenses or certifications
Type State Issued Registration # Effective Date Expiration Date

Work History
Are you currently employed?*
May we contact your current employer?
Employment History*
Please list your current job and previous three jobs.
Start Date End Date Employer Name and Address Position Pay Rate Reason for Leaving
If you would like to upload your resume or CV, you may do so here.
Drop files here or

Accepted file types: pdf, Max. file size: 21 MB, Max. files: 5.
You may upload up to five files simultaneously. Only PDF files are permitted to be uploaded. Microsoft Word files with extensions .doc and .docx cannot be uploaded and must be converted to PDF.

Application Authorization
LECOM Senior Living Center is an equal opportunity employer. No person shall on the basis of race, color, religion, gender national origin, ancestry, ethnicity citizenship, age, genetic characteristics, disability, or any other characteristic protected by applicable law be unlawfully excluded from consideration for employment.

In keeping with LECOM's intent to provide a safe and healthful work environment, smoking or the use of smokeless tobacco products is strictly prohibited in all areas of any LECOM property, including parking lots. This includes use of such products or smoking in cars parked on LECOM property. Employees must also refrain from smoking or using smokeless tobacco products at any time during the shift, even if not on LECOM property.

I authorize LECOM Senior Living Center, or its agent to perform such investigations and inquires of my personal, employment, or medical history and other related matters as may be necessary in arriving a an employment decision. I release employers, schools or persons from all liability in responding to inquires in connection to this application for employment.

I understand and acknowledge that I will be required to have positive employment references and undergo a post-offer pre-employment physical examination, a post-offer pre-employment drug screening, and post-offer pre-employment criminal background check. I understand that these may, the extent permitted by law, result in the revocation of any offer of employment.
I certify that answers given herein are true and complete. I further understand that false or misleading information provided in the employment application or interview may result in canceling further consideration of this application or discharge.*
Email
This field is for validation purposes and should be left unchanged.

Start Date	End Date	Employer Name and Address	Position	Pay Rate	Reason for Leaving

Type	State Issued	Registration #	Effective Date	Expiration Date

Housekeeper - LECOM Health

Step 1 of 6

General Information

Please provide three references who can evaluate you in your professional capacity.

High School Education

College Education

Graduate Education

Technical or Professional Education

Other Education

Professional Licenses or Certifications (Including Nursing and CPR).

Work History

Application Authorization