Application For Employment

Please provide the following contact information:

* Please include your Address - Street, City, State, Zip

* Position Desired- Ex. RN, LPN, Clerk, CNA, or etc.

Current Employer-

Reason for desiring change?

Why do you choose Hospital work?

What prompted you to apply here for employment?

Are you related to anyone in our Employ? Who and How?

* Professional License Numbers, Type, & State

* Please list Schools and Colleges, Major Subject, Did you Graduate?, College Degree, and Attendance (From-To)

* Former Employers and Experience-Name, Address, Nature of Experience, Period (From-To), Salary, Reason for leaving

* List at least 3 Personal References (not relatives)- Name, Address, Phone, Relationship

This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to ability to perform the work required.  No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information.  I consent to take the preemployment physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause.  I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

If you agree with the above statements please proceed by submitting your application.