Test

Personal Data
Legal Name*
First Last
Email*
Phone*
Please enter your primary phone number.
Address*
Street Address Address Line 2 City State ZIP Code
Have you ever interviewed with MAE or any of its affliates (LECOM, Millcreek Community Hospital, LECOM Wellness Center, LECOM Senior Living Center)?*
If yes, please list the affiliate, job title and date.
Have you ever been employed with MAE or any of its affliates (LECOM, Millcreek Community Hospital, LECOM Wellness Center, LECOM Senior Living Center)?*
If yes, please list the affiliate, job title and date.
Do you have any relatives employed with MAE or any of its affliates (LECOM, Millcreek Community Hospital, LECOM Wellness Center, LECOM Senior Living Center)?*
If yes, please list their name, who they are employed by and job title.
Are you a U.S. citizen?*
Are you at least 18 years old?*
Are you at least 16 years old?*
If you are under 18, do you have a valid work permit?*
Are you currently employed?*
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?*
Proof of immigration status will be required upon employment.
How did you learn about this job opening?*
- Advertisement
- Employment Agency
- Friend
- Walk-in
- Relative
- Other

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

Name	Employer	Position	Telephone

Type	State Issued	Registration #	Effective Date	Expiration Date

Test - LECOM Health