Field Service Employment Application

Basic Information

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Contact Details

Primary Phone:	Seconday Phone:
Email Address:

Have you ever been employed by LHE?	Yes No
Have you previously filed an application with LHE?	Yes No

Are you over the age of 18?	Yes No
Do you have a valid Drivers License?	Yes No
Do you have the use of a reliable automobile for work?	Yes No
Can you consistently lift up to 40 pounds?	Yes No
Do you currently have automobile insurance or could you get automobile insurance coverage if hired?	Yes No
Do you own a computer?	Yes No
Do you own a printer?	Yes No
Do you have internet access?	Yes No