Personal
Last Name: First Name: Middle Initial:
Street Address: City: State: Zip:
Position(s) Desired: Home Phone Number:
Cell Phone Number: E-mail:
Hours Available (be specific):
Are you legally eligible for employment in the United States? Yes No
   
Have you ever filed an application with us before? Yes No
If yes, give date:
Have you ever been employed with us before? Yes No
If yes, give date:
Have you ever been involuntarily discharged by an employer? Yes No
If yes, give date:
Have you been convicted of a crime within the last 7 years? Yes No
If yes, give date:
Have you any physical, mental or medical disability which might hinder your work performance? Yes No
If yes, give date:

Education
School Name & Location
Course of Study
Years Completed
Graduation Date/Degree
 
High School      
College      
Business, Technical, Other      

Employment Experience

      
Company Name and Address From To Ending Wage
Supervisor/Telephone# Reason for Leaving Position  
 
       
Company Name and Address From To Ending Wage
Supervisor/Telephone# Reason for Leaving Position  
 
       
Company Name and Address From To Ending Wage
Supervisor/Telephone# Reason for Leaving Position  
 
 

Referral Source

Advertisement Employee Relative Walk-in Job Fair Web Other
 

Applicant's Statement

I certify that answers herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 6 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand, also, that false, misleading or incomplete information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer and in conjunction with any contractual arrangement.

I consent to any and all job-related examinations, including, but not limited to, pre employment health and drug screening or competency tests, as required by St. Elizabeth Medical Center. I agree that any offer of employment, if any, may be made conditional upon successful completion of such examinations and tests. Upon my termination I authorize the release of reference information on my work.

The undersigned has applied for employment at or to volunteer at St. Elizabeth Medical Center. As a condition of St. Elizabeth Medical Center accepting me as an employee or volunteer, I must provide certain information and documents that identify me, my background, my experience and other information or documents. The information or documents that I provide to St. Elizabeth Medical Center are true and accurate to the best of my knowledge. I consent to the Medical Centers disclosure to any third party of information or documents that I provide as an employee or volunteer at the time of application or subsequent to submission of my application in furtherance of any legitimate Medical Center purpose.
 
Name of Applicant: Date: (dd/mm/yy)