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Application for Employment

This institution is an equal opportunity provider and employer.

All statements made by applicants for employment on this application form will be carefully checked for accuracy. We offer equal employment opportunities to all persons without regard to race, religion, age, sex, national origin, or handicap. The use of this form does not mean there are positions open and does not obligate us in any way. This application will remain on active file for ___ months from date of application.

Personal Information

Name (Last, First, Middle):
Home or Nearest Phone:
Present Address:
City:
State:
ZIP Code:
If at present address less than one year, please give previous address:
Social Security Number:
Are you over the age of 18 (*If no, employment is subject to verification that you are of minimum legal age)?:
What languages can you read, speak, and write fluently?:
Are you a citizen of the United States:
If not a citizen of the U.S., can you provide Form 1-151 or Form 1-94 as proof that you can legally be employed in the United States?:
If not a citizen do you intend to remain permanently in the U.S.?:

Positions Applied For:
How soon could you report to work?:
Type of Employment:
Rate of Pay Expected:
What days and hours if part time?
Days:
Hours:

Education

Elementary

Name and Address of School:
Check Last Year Completed:

High School

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

College

Name and Address of School:
Courses Majored In:
Check Last Year Completed:
Did You Graduate?:
Degree:

Describe any other specialized training (such as business, technical, or nursing schooling). Include study courses given through public or private employment.Statewhether degree or certificate was received:
List memberships in professional societies, honors, or fellowships received:
Professional licenses-registrations held:
License number:
Expiration Date:
Issues in what state:

Service in U.S. Armed Forces

Have you served in the U.S. Armed Forces:
If yes, date active duty started:
Which service?:
What branch of that service?:
Starting rank?:
Final rank?:
What were your duties?:

Unemployment

Explain all periods of unemployment other than when you were attending school
Date (From - To):
Explanation:
Date (From-To):
Explanation:
Name three persons (not relatives, former employers, or personnel of this hospital) who have known you for at least two years
Person 1:
Name:
Address:
Business and Position:
Phone:
Person 2:
Name:
Address:
Business and Position:
Phone:
Person 3:
Name:
Address:
Business and Position:
Phone:
Have you applied for a job with us before?:
Have you ever worked for us before?:
How did you come to apply?:
If other, please describe:
Have you ever been bonded?:
Have you ever been refused bond?:
If so, state reason and date:
Have you ever been convicted of a crime except a minor traffic violation?:
If so, state date, court, and place where the offense occurred:
Have you ever been discharged or requested to resign from a position?:
If so, please explain:
Does your present employer know you plan an employment change?:
Why do you desire to make a change?:
Have you ever held a position of trust (handling money or confidential material)?:

Employment History

Account for all periods of employment for the past 10 years, beginning with your present or last position and working back. Include military service. Anaccurate description of your work in each position may be the determining factor in selecting you for employment or for promotion, transfer, or retention afteremployment.
Present or last employer:
Street address:
City:
State:
May we contact?:
Name under which employed:
Employer's phone:
Starting date (month and year):
Leaving date (month and year):
Type of employment:
Starting salary:
Final salary:
Starting position:
Job title:
Supervisor's name and title:
Reason for leaving:
Details of work you preformed:

Previous Employment 2

Next previous employer:
Street address:
City:
State:
May we contact?:
Name under which employed:
Employer's phone:
Starting date (month and year):
Leaving date (month and year):
Type of employment:
Starting salary:
Final salary:
Starting position:
Job title:
Supervisor's name and title:
Reason for leaving:
Details of work you performed:

Previous Employment 3

Next previous employer:
Street address:
City:
State:
May we contact?:
Name under which employed:
Employer's phone:
Starting date (month and year):
Leaving date (month and year):
Type of employment:
Starting salary:
Final salary:
Starting position:
Job title:
Supervisor's name and title:
Reason for leaving:
Details of work you performed:

Job Applicant's Agreement and Certification

"I certify that the information given by me in this application is true in all respects, and I agree that if employed and it is found to be false in any way, that I may be subject to dismissal without notice, if and when discovered. I authorize the use of any information in this application to verify my statements, and I authorise the past employers, doctors, all references, and any other persons to answer all question asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information. I further agree, if employed, that I am to work faithfully and diligently, to be careful and avoid accidents, to come to work promptly, and I am not to be absent for any reason without prior notice to my supervisor, and that employment is terminable at the will of either the employee of employer."

"I agree to be employed on ____ calendar days probationary period and that I may be dismissed at any time during this period at the discretion of the employer. If employed, I agree to observe all present and subsequently issued personel policies and rules. These rules and policies are intended to guide the organization in its relationship with its employees. It is not a contract of employment, and I do not construe it as such. Policies and rules which are issued are not conditions of employment. I understand that the employer may revise policies or procedures, in whole or in part, at any time, with or without notice."

Signature of Applicant:
Date:

 

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