Patient Portal

 

 

  

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Employment Application
General Information
First Name (*)
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Last Name (*)
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M.I.
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Street Address (*)
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City (*)
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State (*)
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Zip (*)
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Phone (*)
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Email (*)
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Psition You Are Applying For (*)
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Are there any hours you cannot work? (*)
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If yes, explain
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Are there any hours you cannot work? (*)
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Date you are available to start working (*)
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Any relatives or friends working for us? (*)
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If yes, give names and locations
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Can you perform essential job functions with or without reasonable accommodations? Describe: (*)
Required Field
Will you be able to provide proof of U.S. citizenship or permanent residency upon employment? (*)
Please specify if you are a U.S. Citizen.
Education
High School Name
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Address
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Grade Completed
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Degree/Major
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College Name
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Address
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Grade Completed
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Degree/Major
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Other Name
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Address
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Grade Completed
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Degree/Major
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Other Name
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Address
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Grade Completed
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Degree/Major
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Employment History (starting with most recent)
Employed From
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To
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Company Name
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Address
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Phone
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Name & Position of Supervisor
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Salary Start
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Salary End
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Your job title and duties
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Reason for left
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Employed from
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To
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Company Name
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Address
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Phone
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Name & Position Of Supervisor
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Salary Start
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Salary End
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Your job title and duties
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Reason for leaving
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Employed from
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To
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Company Name
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Company Address
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phone
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Name & Position of Supervisor
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Salary Start
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Salary End
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Your job title and duties
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Reason For Leaving
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If currently employed, may we contact your employer for reference purposes?
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If yes, give name, position and telephone number of person to be contacted
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1. I hereby declare that the information provided by me in this application is true, correct and complete to the best of my knowledge and that any misrepresentation or falsification of this information shall be considered cause for cancellation of this application and/or separation from LIA's service if I have been employed.

2. I authorize LIA to investigate and check any of the foregoing data and references.

3. I agree to conform to the policies and procedures of LIA and I understand that work schedules are subject to change and that overtime may be required.

4. I understand that just as I am free to resign at any time, LIA reserves the right to terminate my employment at any time, for any lawful reason, with or without cause and without prior notice. I understand that no representative of LIA has the authority to make any statement to the contrary.
Security Code (*) Security Code
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Patient Compliments

Love coming to the Medford Office.  Quality and efficient service.  No long wait time.


I have used Larchmont over the years.  Everyone is kind and helpful, making many appointments for my mother to accommodate my schedule.  Thank you-everyone is great!

 

I go back and forth between NJ and FL.  I always wait until I'm in NJ for imaging so I can come to Larchmont.


Larchmont client for many years (Sunset Rd., Willingboro)-always very satisfied with staff.

 

This team is so amazing!  Everyone was so kind and I was in and out in no time!

 

Entire staff was very knowledgeable and professional.  Every aspect of my test experience was pleasant.

 

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