APPLICATION FOR EMPLOYMENT

This institution does not discriminate in hiring or employment on the basis of race, color, religious creed, national origin, sex or ancestry or on the basis of age or physical or mental handicap unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. This application will be given every consideration, however its receipt does not imply that the applicant will be employed.

Personal Information


*=Required

If you do not have an email address, one may be obtained for free from services such as AOL, Gmail, and Yahoo.


If you cannot be reached at the above phone number, where may we contact you?

Mailing Address

Home Address


Employment Desired

Type of Work Desired

Shift (1, 2, or 3)

Hourly Wage Desired


Education


High School*

College or University

Vocational or Business School

Nursing Education

Laboratory or Radiology Training

Have you received any honors or recognition or do you have any other qualifications that you feel are related to the position for which you are applying?

Professional Licenses And/Or Certifications


Employment Record

(List last or present position first)


Current or Most Recent Employer*

Dates Employed*

Wage*

Position and Duties*

Reason For Leaving*


Previous Employer

Dates Employed

Wage

Position and Duties

Reason For Leaving


Previous Employer

Dates Employed

Wage

Position and Duties

Reason For Leaving


Previous Employer

Dates Employed

Salary Range

Position and Duties

Reason For Leaving


If your former employment references, education or military service are under a name other than indicated on top of this application, please indicate below:


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 understand that I will be required to follow the personnel policies and rules of the institution and that infractions of said rules may lead to dismissal. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

I further understand that this institution follows the unfair employment practice code and there is no discrimination in the hiring of individuals based on sex, race, religion, age, or physical or mental handicap unrelated to ability to perform the work required.

I understand that if I am employed it will be on a probationary or trial basis for a period 90 of days. Upon my termination I authorize the release of reference information on my work.


Availability Record

Are you available to work:


Please Indicate the Days and Hours You Are Available For Work

(Be Specific)


Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

IF YOUR AVAILABILITY CHANGES, IT IS YOUR RESPONSIBILITY TO FILL IN AN "AVAILABILITY CARD" INDICATING THE CHANGES. SUCH CHANGES WILL BE EFFECTIVE, THEN, FOR ANY FUTURE EMPLOYMENT.

I UNDERSTAND THAT EMERGENCY CONDITIONS MAY REQUIRE ME TO TEMPORARILY WORK SHIFTS OTHER THAN THE ONE FOR WHICH I AM APPLYING AND AGREE TO SUCH SCHEDULING CHANGE AS DIRECTED BY MY DEPARTMENT HEAD OR ADMINISTRATOR OF THIS INSTITUTION.

Please double check your application for completeness and click the Submit Application button when you are ready.

Thank you for applying to Refugio County Memorial Hospital.