EMPLOYEE REFERRAL AWARD PROGRAM
Eligible employees of the County of Los Angeles Department of Health Services (LAC-DHS) can receive up to $1000 for each person referred for employment and hired. You, as the applicant, can make this possible by submitting a County Employment Application along with this card.

LAC DHS EMPLOYEE
*First Name:
*Last Name:
*Employee Number:
*Work Area:
*Work Location (hospital or facility):
*Home Phone:
*Work Phone:
*Cell Phone:
*DHS Email Address:
*Personal Email Address::

REFERRAL - NEW EMPLOYEE
*First Name:
*Last Name:
Employee Number:
*California RN License No:
*Hired Date:
*Email Adress:
*Contact Phone Number:
* Required Field