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Employment Form

Name: Address:
City: State:
Zip: Home Phone:
Business Phone: Position Applied For:
Email Address: Salary Desired:
Date Available for Employment:


Are you willing to work:
Overtime (over 40 hrs./wk.)  Yes No On-call  Yes No
Rotating Shifts  Yes No Nights  Yes No
Weekends (Sat./Sun.)  Yes No Holidays  Yes No
Travel  Yes No  


Indicate applicable work skills:
TypingWPM KeypunchSPH
Other job-related skills
Are you applying for Full-time Part-time Temporary
How were you referred to this organization?
Have you ever been employed by this organization? Yes No
If yes, position Department
From To
Do you have any commitments to another employer that might affect your employment with us? Please explain:


Type Name/Address Course of Study Circle last year completed Did you graduate? Diploma/Degree
High School 1 2 3 4 Yes No
College 1 2 3 4 Yes No
College 1 2 3 4 Yes No
Technical,Business or Professional 1 2 3 4 Yes No


Professional Licenses/Certifications:
Type State Exp. Date Registration Number


Please list name, address, and phone number of previous employers with most recent employer first. Periods of unemployment should be included.

From To Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly

Job Title:
Employer name, address, and phone number
Duties:
Reason for leaving:


From To Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly

Job Title:
Employer name, address, and phone number
Duties:
Reason for leaving:


From To Immediate Supervisor Last Salary- Hourly, Monthly, or Yearly

Job Title:
Employer name, address, and phone number
Duties:
Reason for leaving:
May we run an employment check from the employers listed above? Yes No
Has notice been given to present employer? Yes No
Please list references (not relatives or employers) to contact who are acquainted with your work history.


Name Title/Occupation Company/Address Phone Number

Please include any other information you think would be helpful to us in considering you for employment such as additional work experience, publications, activities, accomplishments, etc. (You may exclude all information indicative of age, sex, race, religion, color, national origin, or handicap).

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I understand that my employment can be terminated, with or without cause, at any time at the discretion of the employer or myself. I understand that no management official of the employer other than the chief executive officer of the employer has any authority to enter into any agreement contrary to the foregoing or to make any oral assurance or promise of continued employment to me. I authorize and hold free from liability any persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision.

NOTE for positions in the Cardiology and Cardiac surgery departments: All offers contingent upon the successful completion of references, background checks, pre-employment physical and drug screen.

Print Name: Signature:


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