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London Women’s Care, PLLC is an equal opportunity employer and does not discriminate against applicants or employees on the basis of sex, race, color, religion, national origin, ancestry, or age (40 years of age or older). In addition, the company does not discriminate against qualified individuals with disabilities. By submitting this application, you certify that all information contained in the application is true and complete and acknowledge that the company is relying on the accuracy of the information provided. You authorize the company the verify the accuracy of the information provided and authorize former employers, educational institutions and credit agencies to release information concerning you to the company. You also authorize the company to give references and provide information about you in response to inquiries subsequent to your employment if hired. You understand that falsification, misrepresentation or omission or requested information may result in denial of employment or, if employed, may result in immediate dismissal. You understand and agree that, if hired, your employment will be for no definite period and may, regardless of the date of payment of wages, be terminated at any time without previous notice and with or without reason, at the will of either yourself or the company.

Your Details

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Address *

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Are you at least 18 years of age? *

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If under 18, please list your current age: *

Position Details

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Desired Salary

Days available to work: *

How many hours can you work weekly? *

Type of employment desired: *

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When are you available to start? *

Education, Training, Licensing & Experience

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Professional license type: *

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Professional license number: *

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Professional licene expiration date: *

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Please list any trainings or certifications that you may have:

Personal Details

Are you a current member of the National Guard? *

Yes
No

Have you ever served in the armed forces? *

Yes
No

Have you ever been convicted of a felony? *

Yes
No

If yes, please explain the number of convictions, the nature of offense(s) leading to those convictions, the dates the offense(s) were comitted, the sentence(s) imposed, and the type(s) of rehabilitation you received: *

What is your means of transportation to work? *

Do you have a valid driver's license? *

Yes
No

Driver's license number: *

Driver's license expiration date: *

Driver's license state of issue: *

Type of driver's license: *

Operator
Commercial CDL
Chauffeur

Have you had any auto accidents within the last 3 years? *

Yes
No

If yes, how many? *

Have you had any moving traffic violations within the last 3 years? *

Yes
No

Did a current LWC employee refer you to apply? *

Yes
No

If yes, please name the LWC employee that referred you. *

References

Please provide at least 3 references. At least one reference must be a previous supervisor of manager.

Reference #1 Name *

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Reference #1 Title *

Reference #1 Employer *

Reference #1 Phone *

Reference #2 Name *

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Last

Reference #2 Title *

Reference #2 Employer *

Reference #2 Phone *

Reference #3 Name *

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Reference #3 Title *

Reference #3 Employer *

Reference #3 Phone *

Employment History

Please provide a list of your previous employers.

May we contact your previous employer?

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Previous Employer #1 Company Name *

Previous Employer #1 Address *

Address Line 1

Address Line 2

City

State

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Previous Employer #1 Phone *

Previous Employer #1 Supervisor Name *

First

Last

Previous Employer #1 Employment Start Date *

Are you currently employed with this company? *

Yes
No

Previous Employer #1 Employment End Date *

Reason for leaving *

Previous Employer #1 Salary *

Previous Employer #1 Job Title *

Previous Employer #2 Company Name

Previous Employer #2 Address

Address Line 1

Address Line 2

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State

Zip Code

Previous Employer #2 Phone

Previous Employer #2 Supervisor Name

First

Last

Previous Employer #2 Employment Start Date

Previous Employer #2 Employment End Date

Previous Employer #2 Reason for leaving

Previous Employer #2 Salary

Previous Employer #2 Job Title

Previous Employer #3 Company Name

Previous Employer #3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Employer #3 Phone

Previous Employer #3 Supervisor Name

First

Last

Previous Employer #3 Employment Start Date

Previous Employer #3 Employment End Date

Previous Employer #3 Reason for leaving

Previous Employer #3 Salary

Previous Employer #3 Job Title

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