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Application LucasaCare BG
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Name
*
First
Middle
Last
Maiden Name (if applicable):
Home Phone
*
Work Phone
Other Phone
Email
*
Are you 18 or over?
*
Yes
No
Title of Position Applying for and Date Available to Work
*
Have you been previously interviewed by LucasaCare BG?
Yes
No
If YES, list date(s) and job title(s)
Do you have any relatives currently working for LucasaCare BG?
Yes
No
If YES, list names and relationship to you
Are you employed now?
Yes
No
If YES, may we contact your current employer?
Yes
No
What is the highest level of education you have completed?
*
Please Select
High School Diploma/GED
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Technical or Certificate Program
List the name and locations of all schools, number of years completed, major areas of study and degree/diplomas here:
EMPLOYMENT HISTORY: Employer Name (Please provide information of your last three employers, beginning with the most recent):
*
Job Title and Dates of Employment
*
Job Duties
*
Employer Address
*
Employer Phone Number
*
Weekly Pay at Start of Employment:
Weekly Pay at End of Employment:
Reason for Leaving:
EMPLOYMENT HISTORY: Employer Name
Job Title and Dates of Employment:
Job Duties :
Employer Address:
Employer Phone Number:
Weekly Pay at Start of Employment:
Weekly Pay at End of Employment:
Reason for Leaving:
EMPLOYMENT HISTORY: Employer Name:
Job Title and Dates of Employment:
Job Duties:
Employer Address:
Employer Phone Number:
Weekly Pay at Start of Employment:
Weekly Pay at End of Employment:
Reason for Leaving:
Describe your qualifications for the type of employment you are seeking: (Please include skills, special training, etc)
Please describe your experience working with adults with disabilities:
Reference #1: (name of supervisors, managers, or others who can comment directly on your abilities)
Reference #1 Address and Phone Number:
Reference #1 Relationship/Occupation:
Reference #1 Years Known
Reference #2: (name of supervisors, managers, or others who can comment directly on your abilities)
Reference #2 Address and Phone Number:
Reference #2 Relationship/Occupation:
Reference #2 Years Known:
Reference #3: (name of supervisors, managers, or others who can comment directly on your abilities)
Reference #3 Address and Phone Number:
Reference #3 Relationship/Occupation:
Reference #3 Years Known:
Do you have a valid driver's license?
Yes
No
Driver's License Number and State Issued:
Do you have current vehicle insurance?
Yes
No
Insurance Name and Date of Expiration
Are you willing to undergo a background check in accordance with local law/regulations?
Yes
No
Are you willing to submit to a random drug screening?
Yes
No
Have you LIVED or WORKED outside of Kentucky within the last year?
Yes
No
If yes, which states have you lived in (past 12 months)?
By typing your name and submitting this application, you certify that the facts set forth in this application are true and complete to the best of your knowledge. You understand that if employed, false statements on this application shall be considered sufficient cause of dismissal. You authorize LucasaCare BG to make investigations of your personal references and agree to a background check and drug screening.
Submit
