First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Phone:

Cell Number:

E-mail Address: *

Best Time to Reach You:

Morning
Afternoon
Evening
Night

Have you filled out an application here before:

Yes
No

If Yes, give date:

Have you ever been employed at Lexington before:

Yes
No

If Yes, give date:

Position Applying For: *

Available Start Date: *

Work Availability

Full Time
Part Time
Shift Work
Temporary

If presently employed may we contact your employer:

Yes
No

Previous Employer #1:

Dates Employed:

Supervisor Name:

Phone:

Job Title & Duties:

Reason for leaving

Previous Employer #2:

Dates Employed:

Supervisor Name:

Phone Number:

Job Title & Duties

Reason for leaving

Previous Employer #3

Dates Employed

Supervisor Name:

Phone

Job Title & Duties

Reason for leaving

Highest Level of Education: *

Primary School
High School Diploma
Some College
Bachelors Degree
Graduate / Masters Degree

If you earned a college degree, please list the major:

Referral Source:

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Job Fair
Website
Other
Lexington Employee

If referred by a Lexington Employee please give name:

Have you had any convictions related to moving violations; suspensions, revocations, DWI convictions, or any occurrence involving harm to anyone or property:

No
Not Licensed
Not Applicable
Yes

Please describe conviction:

Have you ever been convicted of a Misdemeanor or Felony: *

Yes
No

If Yes, give date and nature of charge and conviction:

Are there any pending criminal charges, arrests or criminal accusations against you? If yes, please describe:

Have you ever been convicted of client or child abuse, neglect or mistreatment:

No
Yes

If Yes, explain in detail:

Have you ever received disciplinary actions from an employer for client/child abuse, neglect or mistreatment:

No
Yes

If Yes, explain in detail:

Select jobs involve the ability to lift and transfer people. Are you able to perform these job duties if trained:

Yes
No

Do you have any current or former relationships with anyone associated with Lexington that may result in conflict of interest or inappropriate work concerns

No
Yes

If Yes, explain:

Have you ever been excluded by the Federal or State Government from participating in a federal/state funded health care program:

No
Yes

If Yes, explain:

For Positions Requiring Driving - Have you ever been convicted of a motor vehicle moving violation, including but not limited to alcohol and drug-related offenses:

No
Yes

If Yes, state where, when and details:

Habe you ever had your license suspended or revoked, a DWI conviction or any other occurence involving harm to people or property:

No
Yes

If Yes, state when, when and explain in detail:

Have you been a licensed driver for at least the past three years:

Yes
No

If No, how long have you been a licensed driver:

* Required