Lene On Me
314-274-2339
314-528-8007
Office Manager:
314-562-5390
[email protected]
9191 West Florissant Ave. Suite 212 St. Louis, MO 63136
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HOME
ABOUT US
SERVICES
CONTACT US
Careers
BOOK APPOINTMENT
BOOK APPOINTMENT
Careers
APPLICANT INFORMATION
APPLICANT NAME
ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER
EMAIL ADDRESS
DATE OF APPLICATION
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EMPLOYMENT POSITION
How did you hear about this position?
What days are you available for work?
What hours or shift are you available for work?
On what date can you start working if you are hired?
Do you have reliable transportation to and from work?
Salary desired
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PERSONAL INFORMATION
Do you have any friends, relatives, or acquaintances working for Lene On Me Home Healthcare LLC If yes, state name & relationship:
Do you have any friends, relatives, or acquaintances working for Lene On Me Home Healthcare LLC If yes, state name & relationship:
YES
NO
Are you 18 years of age or older?
Are you 18 years of age or older?
YES
NO
Are you a U.S. citizen or approved to work in the United States?
Are you a U.S. citizen or approved to work in the United States?
YES
NO
What document can you provide as proof of citizenship or legal status?
What document can you provide as proof of citizenship or legal status?
YES
NO
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Have you ever been convicted of a criminal offense (felony or misdemeanor)?
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
YES
NO
If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:
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JOB SKILLS/QUALIFICATION
Please list below the skills and qualifications you possess for the position for which you are applying:
(Note: Lene On Me Home Healthcare LLC complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)
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EDUCATION AND TRAINING
HIGH SCHOOL
Name
Location (City, State)
Year Graduated
Degree Earned
COLLEGE/UNIVERSITY
Name
Location (City, State)
Year Graduated
Degree Earned
VOCATIONAL SCHOOL/SPECIALIZED TRAINING
Name
Location (City, State)
Year Graduated
Degree Earned
MILITARY
Are you a member of the Armed Services?
What branch of the military did you enlist?
What was your military rank when discharged?
How many years did you serve in the military?
Do you consent to a pre-employment criminal record check?
Do you consent to a closed record check?
Please disclose all aliases and social security numbers used
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AT-WILL EMPLOYMENT
What military skills do you possess that would be an asset for this position?
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PREVIOUS EMPLOYMENT
EMPLOYER NAME
JOB TITLE
SUPERVISOR NAME
EMPLOYER ADDRESS
EMPLOYER TELEPHONE
DATES EMPLOYED
REASON FOR LEAVING
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EMPLOYER NAME
JOB TITLE
SUPERVISOR NAME
EMPLOYER ADDRESS
EMPLOYER TELEPHONE
DATES EMPLOYED
REASON FOR LEAVING
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REFERENCES
Please provide 3 personal and professional reference(s) below:
REFERENCE 1
CONTACT INFORMATION
REFERENCE 2
CONTACT INFORMATION
REFERENCE 3
CONTACT INFORMATION
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CV
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