LIVE-SCAN/BACKGROUND CHECK

' Los Angeles County Board of Supervisors

Gloria Molina
First District

Mark Ridley-Thomas
Second District

Zev aroslavsky
Third District

!on "na#e
Fourth District

Mi$hael !% Antonovi$h
Fifth District

Miguel &rti'-Marro(uin
Chief Executive Officer

Gail )% Anderson* +r%* M!

Chief Medical Officer

,eggy -a'arey* RChief Nursing Officer

Medical Staff Office 1000 West Carson Street, ox ! Torrance, C" #0$0# Tel% &'10( !!!)!1*1 Fax% &'10( !!!)$+01

To improve health through leadership, service and education

RETURN THIS FORM WITH APPLICATION Health Serv !e" ###$%h"$la!&'(t)$*&v Applicant Name:_______________________________________________________
(print your name legibly as it appears on your professional license)

M.D:

D.O.

Other______

CA Medical Board License number________________________________ Date of birth (mm dd !!!!)

"ersion #$ #% #&

A++l !a(t: (f !ou ha)e pre)iousl! *ent throu+h the bac,+round chec, fin+erprint process (Li)e -can) at .arbor/ 0CLA or at another Count! facilit! please contact the Medical -taff Office at 1#&/$$$/$#2# so that *e ma! )erif! if !ou need to +o throu+h this process a+ain.

3his section is for Di)ision or Department use onl!: .uman 4esources (.4) re5uires the follo*in+ information in order to process a bac,+round chec, (a photo *ill be ta,en for the bad+e *hen the applicant +oes to .4 for Li)e -can bac,+round chec, and fin+erprintin+): #. 6ill this be an unpaid member of the 7rofessional -taff Association (7-A)8 ___9es ___No. $. (f !ou ans*ered :No;< *ho *ill be pa!in+ this applicant8 a.____Count! 7aid =mplo!ee: #.___ >ull/time $. ___7art/time per diem b.____7aid throu+h a Non/Count! 4e+istr! or Contract 7ro)ider Name of Contract 7ro)ider:____________________________ c.____7aid? (ndependent Contract ((n .4< applicant *ill need to complete an (/@ "erification form.) Department:_______________________ Di)ision: ______________________ ____________________________________________________________ -i+nature of Di)ision Chief or Department Chair ____________________________________________________________ 7rinted Name of Di)ision Chief or Department Chair

3his section is for Medical -taff Office use onl!: Bad+e 3itle (chec, one): ____Attendin+ 7h!sician ____7h!sician -pecialist

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