Job Application

for Lady of the Sea General Hospital

* indicates required field

YOU ARE APPLYING FOR THIS POSITION:
FULL TIME 7 On/7 Off Day Shift MT/MLT in Laboratory

1OTHER POSITIONS

If you wish to also apply for any of the other positions we have currently open, please check the appropriate boxes. Click here to return to the Job Listings page.

FULL TIME Clinic Clerk at LOSMC - Cut Off Clinic
FULL TIME Clinic Clerk at LOSMC - Larose Clinic
FULL TIME Inventory Tech in Materials Management
FULL TIME Nursing Assistant in Emergency Department
FULL-TIME Certified Pharmacy Tech at Lady of the Sea Community Pharmacy #1 in Cut Off
FULL-TIME Certified Pharmacy Tech at Lady of the Sea Community Pharmacy #2 in Larose
PART TIME Clinic Clerk at LOSMC - Cut Off Clinic (After Hours)
PART TIME Medical Assistant in LOSMC-Cut Off Clinic
PRN Certified Medical Assistant at LOSMC - Larose
PRN Clinic Clerk at LOSMC - Larose
PRN Housekeeper in Environmental Services
PRN Registered Nurse
PRN Social Worker in Dialysis

2PERSONAL INFORMATION *** First Name:
*** Last Name:
*** Address:
*** Phone Number:
Email Address:
Date Available:
Salary Desired:

3PROFESSIONAL INFORMATION Type of Employment: (check all that apply)
Full-time
Part-time
PRN/FLEX

Days Available: (check all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Hours Available:
Professional Information(if applicable):
Certified Nursing Assistant
Medical Assistant
Phlebotomist
Med Lab Tech
Med Tech
LPN
RN
Respiratory Therapist
Pharmacist
Other License (please provide type)
Are you:
*** A previous employee?  Yes  No
*** 18 or over?  Yes  No
*** A citizen of the United States?  Yes  No
*** Legally able to work in the U.S.?  Yes  No
*** A licensed driver with a car available for work?  Yes  No

*** Fully vaccinated for COVID-19?  Yes  No
In accordance with Centers for Medicare and Medicaid Services (CMS), Lady of the Sea is requiring all healthcare workers to be fully vaccinated against COVID-19, or healthcare workers must apply for and be granted either a Medical Exemption or Religious Accommodation. Download vaccination accommodation request here.

Please tell us how you became informed about this position: (choose one)
The Lafourche Gazette
Houma Courier or Daily Comet
Facebook
Lady of the Sea website
Family or Friends
Other

4EDUCATION High School or Trade School Name and Location:
------Business or Tech------
Name and Location:
Dates Attended:
Name and Date of Degree Earned:
Major Field of Study:
------College or University------
Name and Location:
Dates Attended:
Name and Date of Degree Earned:
Major Field of Study:
------Other Training------
Name and Location:
Dates Attended:
Name and Date of Degree Earned:
Major Field of Study:

5REFERENCES ------Employment Reference (1)------
Company Name:
Manager/Supervisor:
Company Phone/Fax:
Dates of Employment: (from ____ to ____)
Your Position/Title:

------Employment Reference (2)------
Company Name:
Manager/Supervisor:
Company Phone/Fax:
Dates of Employment: (from ____ to ____)
Your Position/Title:

------Employment Reference (3)------
Company Name:
Manager/Supervisor:
Company Phone/Fax:
Dates of Employment: (from ____ to ____)
Your Position/Title:

------Employment Reference (4)------
Company Name:
Manager/Supervisor:
Company Phone/Fax:
Dates of Employment: (from ____ to ____)
Your Position/Title:

------Personal Reference (1)------
Reference Name:
Address:
Phone Number:
Occupation:
------Personal Reference (2)------
Reference Name:
Address:
Phone Number:
Occupation:

7NEPOTISM

NOTICE: Immediate family members of the Board of Commissioners and CEO may not be eligible to work at this facility. Also, immediate family members of Managers may not be eligible to work in that manager's department.

*** Do you have a relative who is a member of the Board of Commissioners at Lady of the Sea?
Yes No
*** Do you have a relative employed at Lady of the Sea?
Yes No
If yes, list name(s) and relationship:

8APPLICANT STATEMENT

I certify that all information given on this application is true, correct and complete.
I certify that I have accounted for all of my work experience and training.
I understand that any false information, willful or negligent misrepresentation, or failure to disclose any requested information will constitute sufficient grounds for Lady of the Sea General Hospital to cancel consideration for employment or to terminate my employment without notice.
I authorize any inquiry to be made on any information contained in this application.
I authorize any previous employers, schools, or persons named as reference to give any information regarding my employment offer is not tendered, is withdrawn or my employment is terminated of falsity of statements, answers or omissions made by me in this application.
I hereby release said employers, schools, or persons from all liability for any damages whatsoever for issuing this information.
I agree to submit to a physical examination and drug screening and understand that provided Lady of the Sea General Hospital otherwise wishes to hire me, my employment at Lady of the Sea General Hospital depends upon the results of such examination and screening being acceptable to Lady of the Sea General Hospital.
I understand that operating conditions may require me to temporarily work shifts other than the one for which I am applying and I agree to such scheduling changes as directed by my supervisor/manager.
I further understand that an offer of employment does not constitute a contract between the applicant and Lady of the Sea General Hospital.
I understand that if employed, such employment is for an indefinite period, may be terminated by Lady of the Sea General Hospital or the applicant at any time with or without cause, and is subject to change in wages, conditions, benefits, and operating policies at Lady of the Sea General Hospital.
If employment is obtained under this application, I will comply with all policies and procedures of Lady of the Sea General Hospital.
I have read the description of the position available that I am applying for and can meet the physical requirements thereof.

*** IF YOU AGREE WITH THIS STATEMENT, PLEASE TYPE YOUR INITIALS HERE

Lady of the Sea General Hospital does not discriminate on the basis of any protective status.

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Latest application revision: 04/2013

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