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Application
Complete the form below to express your interest in employment with Lawrence County Memorial Hospital.
Personal Information
First Name:
MI:
Last Name:
Address:
City:
State:
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Zip Code:
Please list any previous names:
Phone:
E-mail:
Are you at least 18:
Yes
No
Are you willing to take the required Drug Tests?:
Yes
No
Have you been employed here before?:
Yes
No
Do you have a valid drivers license?:
Yes
No
Have you ever been debarred or excluded from participation in Medicare, Medicaid or any other federal or state funded health care program?:
Yes
No
Please provide an explanation and current status:
Position
Position desired:
General Application
Environmental Services - Part Time Environmental Services Technician
Food & Nutrition Services - Cook
Laboratory - Medical Technologist
Patient Financial Services - Director of Patient Financial Services
Patient Financial Services - Patient Account Representative
Pharmacy - PRN Pharmacist
Radiology - Radiology Technologist
Desired Salary:
Education
School or Program:
Years Completed:
Degree or Accreditation earned:
Major or Subject:
School or Program:
Years Completed:
Degree or Accreditation earned:
Major or Subject:
School or Program:
Years Completed:
Degree or Accreditation earned:
Major or Subject:
Employment History
Employer 1:
Employer Address:
Employer Phone Number:
Job Start Date:
Job End Date:
Job Title:
Responsibilities:
Reason for leaving:
Employer 2:
Employer Phone Number:
Employer Address:
Job Start Date:
Job End Date:
Job Title:
Responsibilities:
Reason for leaving:
Employer 3:
Employer Phone Number:
Employer Address:
Job Start Date:
Job End Date:
Job Title:
Responsibilities:
Reason for leaving:
Please explain any gaps in your employment, other than those due to personal illness, injury or disability.:
If not addressed in previous answers, if you have been fired or asked to resign from a job, please provide details:
Upload your Resume:
Release
I certify that I have read, fully understand and accept all terms of this Applicant Statement and Release.:
Yes
No
Current Openings
Employee Benefits
Application
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