Date of Application*

Position applied for*

Referred to our hospital by*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Alternate Contact Phone*

Best time to call?*

May we contact you at work?*

Yes
No

If yes, work phone

Best time to call at work?

Are you at least 18 years of age?*

Yes
No

Have you applied for a position previously?

If yes – date & position applied

Are you legally eligible for employment in this country?*

Yes
No

Date available to start work*

Desired salary/hourly rate*

Type of employment desired*

Full-time
Part-time
Seasonal

Are you able to perform the requirements described in the job description?*

Yes
No

Will you work overtime if required?*

Yes
No

If no please explain

Are there any animals you cannot work with?*

Yes
No

If yes please explain

EMPLOYMENT HISTORY

Please start with your most recent employer and provide the following information.

1. Employer*

Phone*

Dates employed (Start date - End date)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title*

Starting Wage*

Ending Wage*

Immediate Supervisor/ Title*

Reason for leaving*

May we contact for reference?*

Yes
No

Please summarize your job responsibilities*

2. Employer

Phone

Dates employed (Start date - End date)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Starting Wage

Ending Wage

Immediate Supervisor/ Title

Reason for leaving

May we contact for reference?

Yes
No

Please summarize your job responsibilities

3. Employer

Phone

Dates employed (Start date - End date)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Starting Wage

Ending Wage

Immediate Supervisor/ Title

Reason for leaving

May we contact for reference?

Yes
No

Please summarize your job responsibilities

SKILLS & QUALIFICATIONS

Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position:

EDUCATIONAL BACKGROUND*

List all: School (Include City & State) | # of years completed | Level of completion/ Degree | Course of Study

REFERENCES (Persons not related to applicant)*

List 3: Name | Title/Profession | Relationship to applicant | Telephone | # of years known

APPLICANT STATEMENT

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal & professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I also understand the employer will perform a background check. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that a negative drug test result may be required by the employer prior to employment to comply with the employer’s drug-free workplace program. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application, or immediately discharge me from the employer’s service, whenever it is discovered.

Consent*

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Do not sign until you have read the above applicant statement.

Name of Applicant*

First Last

Date*

Careers

Application for Employment

EMPLOYMENT HISTORY

SKILLS & QUALIFICATIONS

APPLICANT STATEMENT

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