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Employment Application
We consider applicants for all positions without unlawful discrimination on the basis of protected status
including race, color, religion, sex, national origin, age, marital status, Vietnam era or disabled veteran status, or disability
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Indicates required field
Position Applied For
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How did you hear about us?
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Advertisement
Employment Agency
Employee
Walk-In
Internet
Other
If Advertisement - Name of Publication
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If Employment Agency - Name of Agency
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If Employee - Name of Employee
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If Other, Please Specify
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Name (First Middle Last)
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Date
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Position Applied For
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Social Security Number
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Street Address
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Email Address
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State
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Phone Number
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Zip Code
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Date of Birth
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If previously employed under different name, state name
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On what date would you be available for work?
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Wages Expected
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Available to work:
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Full Time
Part Time
Time Available
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Day
Evening
Night
Any
Weekends:
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Available
Not Available
Please select all that apply
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I am under the age of 18 and can provide required proof of my eligibility to work
I am a US citizen or authorized to work in this country (Proof of citizenship or immigration will be required upon employment)
I am a previous applicant
I am a previous employee
I am on layoff status and subject to recall
Work Experience
Please provide the following information. A resume providing this information may be submitted only as supplement.
Note: Start with present or most recent job. Furnish dates and explanation for each period of unemployment of one month or more.
Employer (Present or Last)
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Address of Company
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Telephone Number
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Dates Employed (From - To)
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Hourly Rate/Salary
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Work Performed
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Job Title
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Supervisor
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Reason for Leaving
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May we contact your present employer?
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Yes
No
Employer
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Address of Company
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Telephone Number
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Dates Employed (From - To)
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Hourly Rate/Salary
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Work Performed
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Job Title
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Supervisor
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Reason for Leaving
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Employer
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Address of Company
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Telephone Number
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Dates Employed (From - To)
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Hourly Rate/Salary
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Work Performed
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Job Title
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Supervisor
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Reason for Leaving
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Education and Training
School Name
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Location
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Graduation Date
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Degree Earned
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Major and Minor Fields of Study
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Special Awards
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School Name
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Degree Earned
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Location
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Major and Minor Fields of Study
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Graduation Date
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Special Awards
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School Name
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Degree Earned
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Location
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Major and Minor Fields of Study
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Graduation Date
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Special Awards
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Additional Qualifications
What knowledge, special technical skills, and/or capabilities do you have that especially prepare you for this position?
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Foreign Languages
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Fluency
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Speak
Read
Write
MILITARY
Branch of Service
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Rank at Discharge
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Dates of Service
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Duties, including school and training
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List professional, trade, business, or civic activities and offices held. Exclude organizations which indicate race, color, religion, gender, national origin, disability, or other protected status.
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Awards Held?
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Current professional License or Registration number:
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State
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If applying for a position as an RN, LPN, Respiratory Therapist, or CNA, please check all that apply
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CPR Certified
Heart Saver/BLS
IV Trained
ACLS Certified
Critical Care Course
Telemetry Course
Arrhythmia Course
ED Course
Professional References
Please provide complete information for three professional references
Name
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Address
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Telephone
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Relationship
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Name
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Telephone
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Address
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Relationship
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Name
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Address
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Telephone
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Relationship
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Applicant Statement
I understand that federal Law prohibits the employment of unauthorized aliens; all persons hired must submit satisfactory proof of employment authorization and identity; failure to submit such proof will result in denial of employment.
I understand that any offer of employment that may be made by Prevost Memorial Hospital (PMH) is conditioned on the results of a post-offer physical examination and drug screening through urinalysis. The medical provider(s) of said examination will be designated by PMH and will be at the company's expense.
I understand that neither this application not any handbook or personal policies manual I receive from PMH is intended to create a contract for employment for any particular duration or with any particular terms and conditions.
I understand that employment with PMH is at will and may be terminated at any time by the employer or the employee for any reason not prohibited by law unless different terms and conditions are set forth in writing signed by the Human Resources Director and the Administrator of PMH.
I hereby agree not to share my assigned User ID/Password with anyone else. Any use of discussion of information on the Hospital Computer Systems or its product must be approved by Department Managers. I will follow any rules set by the IT Department pertaining to the Informations Systems.
I certify that all statements herein are true and I understand that any falsification or willful omission of information in the employment process may result in dismissal or refusal of employment.
Applicant Signature
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First
Last
Please provide your full professional name for your signature
Please List Employers and Educational Institutions that PMH may contact for verification purposes.
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Date
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I authorize the release of any information in your files concerning my enrollment or employment in your organization to representatives of PMH and I release any organization or individual providing such information to PMH representatives from any and all liability for damage resulting therefrom.
Applicant Signature
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First
Last
Please provide your full professional name for your signature
Date
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Submit
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