Los Angeles County Department of Health Services
LACounty.gov Enriching lives through effective and caring services County Directory of Information & Services  |  Public Alerts  |  Public Information  |  County Contact Information
Los Angeles County Department of Health Services
Los Angeles County
Health Services
Home  |  About Us  |  Patient Information  |  Employment  |   |  Departments  |  Search
Font Size: A A A
DHS Internal Services Intranet Login  |  Provider Login
 
Online Forms

Online Workforce Member

 
LOS ANGELES COUNTY
DEPARTMENT OF HEALTH SERVICES
 INFORMATION SHEET
*  
*Sponsor Facility: *Sponsor Division: *Sponsor Name:

As appeared on your identification card:
*1. Last Name: *First Name: MI: *Gender: *Social Security Number:
   -     - 
Other Name(s) Used  
*2. RESIDENCE - Street and Number: *City: *State: *Zip:
*3a. Do you have a relative currently employed by the County ?
 If yes*, indicate Name, Relationship And Department:
*3b. Have you ever worked previously or currently for the County as an employee or contractor   (including independent or agency)?
Employee No. Department Name Date worked (From/To)
If so*, provide:
4. Residence (at the above address) since: *Telephone No : *Email Address:
*5. Date of Birth: California: Los Angeles County:
6. Date residency established in:
  *Name: *Telephone No.:
*7. In case of emergency, notify:
Street and Number: City, State, and Zip:
8. Military Service in the Armed Forces of the United States: From: To: Serial Number:
    Highest Rank or Rating  Branch  Type of Discharge
9.  Military Service as a Reservist From To
10.  Credential Type: Identification No.: Identification Issued From (Country /State):
CHECK
11. Foreign Languages Read Write Speak
Spanish
Other    
Other    
Other    
12. Education (Name and location of School) Last Grade Completed Date Completed College Major Degrees or Diploma
Grammar and High School 
College/University   
Other  
Other  
*13. Do you have a Professional or Technical Licenses, Permit, etc., that is required for this position?
License Serial No. Expiration Date Board Agency State, County, or City which registered
*14. A full disclosure of all convictions is required. Failure to disclose convictions will result in disqualification. Not all convictions constitute an automatic bar to employment. Factors such as age at the time of the offense(s), and the recency of offense(s) will be taken into account, as well as the relationship between the offense(s) and the job for which you are being appointed. However, any applicant or employee for County employment who has been convicted or worker's compensation fraud is automatically barred from employment with the County of Los Angeles (County Code Section 5.12.110).
ANY CONVICTION OR COURT RECORDS WHICH ARE EXEMPTED BY A VALID COURT ORDER DO NOT HAVE TO BE INCLUDED.
* Have you ever been convicted of a misdemeanor or felony in criminal proceeding or by a military court?
*14a.   Offense or Case Name   Case Number Conviction & Order Date Location of the Court (City and State) Sentence or Fine
(Provide Penal or other code section if known)
* Required Field PAGE 1 OF 2 Next >>
 
 
Safely Surrendered Baby

DHS Home   |   lacounty.gov   |   Email: Webmaster   |  Notice of Privacy Practices   -  English | Spanish   |   Website Privacy Statement   |   Disclaimer   |   Administrative Use

  Joint Notice of Privacy Practices  -  English | Spanish
Los Angeles County Seal: Enriching lives through effective and caring services