LCFS Online Application for Employment
 
Please enter complete and accurate information in the spaces below.
 
Position applying for: 
 
Social Security Number:    -   - 
 
Legal Name:    First:   Middle:   Last: 
 
Email  
 
Address: 
City:  
County:  
State:    Zip+4: -
 
Phone Numbers - Please enter at least one valid contact number.
Home #:    - -
Cell #:       - -
Other #:    - -
 
Date of Birth  / /
Are you 
 
Education
a: Check highest grade completed 
b: If you didn't complete high school, do you have a high school equivalency diploma? 
c: Check number of years of post high school education 
 
Name of College/University/Institution
1 
Hrs. Degree
Received		 Major or
Speciality		 Minor Dates
Attended
          - 
Name of College/University/Institution
2 
Hrs. Degree
Received		 Major or
Speciality		 Minor Dates
Attended
          - 
Name of College/University/Institution
3 
Hrs. Degree
Received		 Major or
Speciality		 Minor Dates
Attended
          - 
 
If you expect to complete an education program in the near future (12 - 18 months), please
indicate what type of degree or program and expected completion date:
 
Are you a RN?     If yes, RN #:  
 
Are you a LPN?     If yes, LPN #:  
 
Are you a CNA?     If yes, CNA #:  
 
Do you have First Aid Certification?     If yes, Exp. Date:    / 
Do you have CPR Certification?     If yes, Exp. Date:    / 
Other  Certifications: 
 
Work References - All references must be work related references such as supervisors.
 
Reference 1 
Name:  
Company Name:  
Title:   
Phone Number:  - -
 
Reference 2 
Name:  
Company Name:  
Title:   
Phone Number:  - -
 
Reference 3 
Name:  
Company Name:  
Title:   
Phone Number:  - -
 
Work History - FIVE (5) YEAR MINIMUM
Starting with the most recent, describe ALL paid, military and applicable voluntary experience.
Highlight your knowledge, skills and abilities which best demonstrate your qualifications for
this position. If you need more space please fax in written or typed pages with your full name
on each page to (678) 244-9141.

May we contact your present supervisor? 
 
Employer 1:
Employer:    Job Title: 
Immediate Supervisor:    Title: 
Address: 
Phone #: - -
Salary: (start) $  (finish) $
Dates: from (mm/yyyy)   to (mm/yyyy) 
Job Status:     Hours/week: 
Number and titles of employees you supervised: 
Equipment used: 
Reason for leaving: 
Name if different from present: 
Duties:
 
Employer 2:
Employer:    Job Title: 
Immediate Supervisor:    Title: 
Address: 
Phone #: - -
Salary: (start) $  (finish) $
Dates: from (mm/yyyy)   to (mm/yyyy) 
Job Status:     Hours/week: 
Number and titles of employees you supervised: 
Equipment used: 
Reason for leaving: 
Name if different from present: 
Duties:
 
Employer 3:
Employer:    Job Title: 
Immediate Supervisor:    Title: 
Address: 
Phone #: - -
Salary: (start) $  (finish) $
Dates: from (mm/yyyy)   to (mm/yyyy) 
Job Status:     Hours/week: 
Number and titles of employees you supervised: 
Equipment used: 
Reason for leaving: 
Name if different from present: 
Duties:
 
Employer 4:
Employer:    Job Title: 
Immediate Supervisor:    Title: 
Address: 
Phone #: - -
Salary: (start) $  (finish) $
Dates: from (mm/yyyy)   to (mm/yyyy) 
Job Status:     Hours/week: 
Number and titles of employees you supervised: 
Equipment used: 
Reason for leaving: 
Name if different from present: 
Duties:
 
Employer 5:
Employer:    Job Title: 
Immediate Supervisor:    Title: 
Address: 
Phone #: - -
Salary: (start) $  (finish) $
Dates: from (mm/yyyy)   to (mm/yyyy) 
Job Status:     Hours/week: 
Number and titles of employees you supervised: 
Equipment used: 
Reason for leaving: 
Name if different from present: 
Duties:
 
Drivers License
License Type:    License #:    Issuing State
 
Miscellaneous
Select which shifts you will accept:
(Hold down the "Ctrl" key while clicking on each shift you wish to select)

Specify preferred shift hours 
Select which job status you will accept:
(Hold down the "Ctrl" key while clicking on each job status you wish to select)
Do you have access to a vehicle?   If yes,
If no, can you provide your own transportation for employment?
Select the counties in which you are willing to work:
(Hold down the "Ctrl" key while clicking on each county you wish to select)
When are you available to start work? / /
Are you a United States Citizen? 
If NO, do you have a work visa? 
Have you ever been convicted* for any violation(s) of law, including moving traffic violations? 
If YES, you will need to provide the following Description of Offense(s) by fax. (678) 244-9141
Statute or ordinance(if known): Date of Charge: Date of Conviction: County, City, State of Conviction.
*Convictions include juvenile adjudications for Capital Murder, First and Second Degree Murder,
Lynching, or Aggravated Malicious Wounding, if you were age fourteen (14) to eighteen (18) when
charged.
 
CERTIFICATION - I hereby certify by typing today's date and my full name in the spaces provided below
that all entries entered on this online Application for Employment are true and complete, and I agree and
understand that any falsification of information herein, regardless of time of discovery, may cause
forfeiture on my part of any employment in the service of Loving Care Family Services, LLC (LCFS).
I understand that all information on this application is subject to verification and I consent to a FBI
criminal history background check. I also consent for LCFS to contact references, former employers
and educational institutions listed regarding this online application. I further authorize LCFS to rely upon
and use, as it sees fit, any information received from such contacts. Information contained on this
online application may be disseminated to other agencies, nogovernmental organizations or systems on
a need-to-know basis for good cause shown as determined by the agency head or designee.
Today's Date  / /
Full Name