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Parental Consent for Health Evaluation Acknowledgement-Voluntary Attending Staff Acknowledgement-Contract/Registry Staff,Non-County Residents/Fellows/Affiliates Acknowledgement-Volunteers,Students Acknowledgement-Independent Contractors Non-County Packet Comprehensive Policy Statement Code of Conduct Patient Privacy and Confidentiality Packet

Online Workforce Member   LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES  INFORMATION SHEET  *   New Assignment Re - Assignment Additional Position Transfer Sponsor Facility: * Sponsor Division: * Sponsor Name: * Harbor-UCLA Medical CenterHigh Desert MACCHSAMartin Luther King, Jr.MID VALLEYOLIVE VIEW - UCLARancho Los Amigos N.R.C.TRAINING 1. Last Name*: First Name*: M: Gender*: Social Security Number: * FMUnknown    -     -  2.RESIDENCE - Street and Number*: City*: State*: Zip*: 3a. Do you have a relative currently employed by the County ?* Yes No   Indicate Name, Relationship And Department: 3b. Have you ever previously worked for the County as an employee or contractor*   (including independent or agency)? Yes No If so, provide Employee No., Indicate when and for what Department : 4. Residence Since (date): Telephone*: Email Address*: 5. Date of Birth:* California: L.A. County: 6.Date residency established: 7. In case of emergency, notify: Telephone: Street and Number: City: 8.  Credential Type: Driver License/Passport/ID#: License/Passport/ID Issued From: Driver LicensePassportID 9. List office and shop machines you can operate:      10. List heavy equipment you can operate:      11. If the position for you are applying requires operating a vehicle on the job, please furnish: Operators or Chauffeurs License Serial No: Expiration Date: CHECK 12. Foreign Languages Read Write Speak Spanish French Other     13. Educaton:  Name and location of School Last Grade Completed Date Completed College Major Degrees Grammar and High School  Other   Other   14. Professional or Technical Licenses, Permits, etc.(Show state, county or city in which registered):*      15. Have you ever been convicted of a misdemeanor or felony in any court (including traffic court)?*      Yes No   if, "Yes" give the following information for each offense (user additional sheets if necessary): DATE OF CONVICTION POLICE DEPARTMENT OR COURT CHARGE DISPOSITION PRIOR CONVICTIONS WILL NOT AUTOMATICALLY BAR EMPLOYMENT; HOWEVER, FAILURE TO FULLY AND ACCURATELY DISCLOSE PRIOR CONVICTIONS MAY CONSTITUTE GROUNDS FOR DISQUALIFICATION AND / OR IMMEDIATE TERMINATION. * Required Field PAGE 1 OF 2 Next >>