LA County Department Of Health Services

*Please provide your c+Contractor Number (e.g. c012345) or e+Employee Number (e.g. e123456) for 'Re - Assignment', 'Additional Position', 'Transfer', 'County Rotation'.

*Sponsor Facility:

*Sponsor Division:

*Sponsor Name:

*Agency:

As appeared on your identification card:

*1. Last Name:

*First Name:

MI:

*Gender:

*Social Security Number:
- -

Other Name(s) Used:

Marital Status:

*Ethnicity:

*2a. RESIDENCE - Street and Number:

*City:

*State:

*Zip:

2b. Date Residency established in California:
mm/dd/yyyy

2c. Date Residency established in Los Angeles County: mm/dd/yyyy

*3. Do you have a relative currently employed by the County?

Yes No

*3a.

Have you ever worked previously or currently for the County as an employee or contractor (including independent or agency)?

Yes No

*If so, provide:

Employee No.

Department Name

Date worked (From/To)

*4. Date of Birth:

*Telephone No.:

*Email Address:

*5. In case of emergency, notify:

*Name:

*Telephone No.:

Street Name and Number:

City, State, and Zip:

6. Credential Type:

Identification No.:

Identification Issued From (Country /State):

* 7. Education Click here if "None"

(Name and location of School)

Last Grade Completed

Date Completed

College
Major

Degrees or
Diploma

High School

College/University/Technical School

Other

*8. Do you have a Professional or Technical Licenses, Permit, etc., that is required for this position?

Yes No

License Serial #

Expiration Date

Board Agency

State, County, or City which registered

*9. Employment History: Begin with present or last experience. Account for past 6 years or past 6 employers.

Click here if "None"

From Mo-Yr

To
Mo-Yr

Time In Mo.

Position or Occupation

Duties performed

Name and addresses of all former employers including other County depts. as well as private firms

Reason for Leaving

*10. Have you ever been fired or discharged?

Yes No

If yes, please provide details but do not include criminal conviction information. (REQUIRED, limited 500 characters)

PARENTAL CONSENT FOR MINORS

CONDITION OF ASSIGNMENT FORMS (Check One)

LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Check 1a.)

1a.

As a Voluntary Attending Staff member, I am an officially enrolled Volunteer of the County, and I understand that the County will defend and insure me against any liability resulting from an act or omission occurring during the course and within the scope of my practice within any County facility. I also understand, however, that the County will not defend or insure me from liability resulting from my actual fraud, corruption or actual malice.

LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Check 2a.)

2a.

I am a Contract/Registry Staff, Non-County Resident/Fellow/Affiliate, and I understand that any Liability Insurance and Workers Compensation Benefits afforded to me are the responsibility of my employer or academic institution, unless otherwise contractually provided, and the County of Los Angeles shall be held harmless and will not defend or insure me in any action taken against me as a result of my acts or omissions, whether conducted within, or outside of, my approved scope of practice, within any County facility.

LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Choose the statement that applies to you)

3a.

I am a student, and I understand that any Liability Insurance and Workers Compensation Benefits afforded to me are the responsibility of my sponsoring academic institution, agency or employer, unless otherwise contractually provided. The County of Los Angeles shall be held harmless and will not defend or insure me against any liability resulting from any act of omission whether arising within, or outside of, the course of scope of my assignment.

3b.

I am an officially enrolled Volunteer of the Los Angeles County Department of Health Services, and I understand that the County will defend and insure me against any liability resulting from an act or omission occurring during the course and scope of my volunteer work assignment. I also understand, however, that the County will not defend or insure me from liability resulting from my actual fraud, corruption or actual malice.

LIABILITY INSURANCE AND WORKERS COMPENSATION BENEFITS (Check 4a.)

4a.

I am an Independent Contractor, and I understand I am responsible for providing and maintaining each of the types and limits of commercial insurance coverage which are specified by the terms of my County service agreement/contract unless otherwise provided or waived by the County. The County of Los Angeles shall be held harmless and will not defend in any action taken against me as a result of my activities within any County facility.

SCOPE OF ASSIGNMENT (Check One)

MANDATORY FORMS [ALL CHECKBOXES MUST BE CHECKED]

Acknowledgment of form, please check the box below if you agree with the "Acknowlegment of County IT Resource Use Policy"

MANDATORY FORMS [ALL CHECKBOXES MUST BE CHECKED]