Application - Sullivan County Memorial Hospital

Sullivan County Memorial Hospital » Application

APPLICANT TO COMPLETE ALL INFORMATION REQUESTED.

In compliance with Federal and State employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status disability or any other protected group status.

APPLICATION FOR EMPLOYMENT

First Name

Middle Name

Last Name

Present Address

City

State

Zip Code

Cell Phone

Alternate Number

Please list any other name(s) which you have been known by at previous employers or educational institutions:

Do you currently use tobacco/nicotine products?**

No Yes

Do you have a legal right to be employed in the United States?

No Yes (proof required)

Are you over the age of 18?

No Yes

Have you ever been convicted of a felony?

No Yes

If yes, please explain:

Have you ever been excluded from providing patient care to those receiving Medicare or Federally funded health care programs?

No Yes

If yes, please explain:

Do you have a record of founded child or dependent adult abuse?

No Yes

If yes, please explain:

Have you worked for Sullivan County Memorial Hospital before?

No Yes

Date From:

Date To:

Department

Position:

Reason for leaving:

GENERAL

Are you currently employed?

No Yes

If not, last date of employment?

Position applying for?

If applying for part-time, hours available per week:

How did you become aware of this position?

Rate of pay expected:

Available start date:

College Name & City

Did you graduate?

No Yes

Course or Major

Grad School Name & City

Did you graduate?

No Yes

Course or Major

Technical School Name & City

Did you graduate?

No Yes

Course or Major

Highschool Name & City

Did you graduate?

No Yes

Course or Major

Other Name & City

Did you graduate?

No Yes

Course or Major

LIST ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH MOST RECENT

Current Employer Name

Address

Business Phone

Type of Business

Name of Supervisor

Position(s) Held

Date Worked From

Date Worked To

Duties & Responsibilities

Reason for Leaving

Starting Wage

Ending/Current Wage

Previous Employer Name

Address

Business Phone

Type of Business

Name of Supervisor

Position(s) Held

Date Worked From

Date Worked To

Duties & Responsibilities

Reason for Leaving

Starting Wage

Ending Wage

Work References

Company Name

Address

Years Known

Relationship & Title

Home Phone

Work Phone

Special Skills

Please check the skills for which you have received training

EMR Training

Brand Name used

Speak, read, or write any language other than English?

Please describe

Health Care Equipment

Please describe

Certifications held

If applicable, any other professional credentials that would relate to the position for which you are applying: