Memorial Health Care Systems - Employment Application

Date:

- Month - Day Year

Applicant Name:*

E-mail:

Phone/Message Number:*

- Area Code Phone Number

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Applying for Position(s):

Referral source:

Advertisement Employee Employment Agency Relative Walk-in Job Hotline Website Other

Name of referral source:

Type of employment desired:

Regular Temporary Full-time Part-time PRN (as needed)

Shift preference:

Days Evenings Nights No preference

Are you available to work:

Weekends Holidays Rotating shifts

Date you will be available to start work:

- Month - Day Year

Can you perform the essential functions of the job (s) for which you are applying, as you understand them, with or without reasonable accommodation?:

Yes No

Are you able to meet the attendance requirements?:

Yes No

Do you have any objection to working overtime if necessary?:

Yes No

Can you travel if required by this position?:

Yes No

Have you ever been previously employed by our organization?:

Yes No

If "yes," which entity:

Sundermann Homes Memorial Hospital Milford Family Medical Center Seward Family Medical Center Utica Family Medical Center

Dates of Employment:

Can you submit proof of legal employment authorization and identity?:

Yes No

Are you over 18 years of age?:

Yes No

If not, are you over 16 years of age?:

Yes No

Have you ever been convicted of a crime?:

Yes No

If yes, please explain:

If you are presently employed, why do you wish to leave your present position:

Employer 1:

Position held:

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

- Area Code Phone Number

Dates employed (from-to):

Immediate supervisor and title:

Salary:

$

Reason for leaving:

May we contact this employer for a reference?:

Yes No

Employer 2:

Position held:

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

- Area Code Phone Number

Immediate supervisor and title:

Dates employed (from-to):

Salary:

$

Reason for leaving:

May we contact this employer for a reference?:

Yes No

Employer 3:

Position held:

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

- Area Code Phone Number

Immediate supervisor and title:

Dates employed (from-to):

Salary:

$

Reason for leaving:

May we contact this employer for a reference?:

Yes No

Employer 4:

Position held:

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number:

- Area Code Phone Number

Immediate supervisor and title:

Dates employed (from-to):

Salary:

Reason for leaving:

May we contact this employer for a reference?:

Yes No

Comments (including gaps in employment):

Additional skills and/or qualifications:

1. School (City, ST, Zip):

Phone Number:

- Area Code Phone Number

Years Completed:

Degree/Diploma:

Major:

Minor:

Are you presently attending school or taking classes?

Yes No

If "yes," where are you enrolled and what course of study are you pursuing?:

What is your estimated graduation date:

2. School (City, ST, Zip):

Phone Number:

- Area Code Phone Number

Years Completed:

Degree/Diploma:

Major:

Minor:

Are you presently attending school or taking classes?:

Yes No

If "yes," where are you enrolled and what course of study are you pursuing?:

What is your estimated graduation date:

3. School (City, ST, Zip):

Phone Number:

- Area Code Phone Number

Years Completed:

Degree/Diploma:

Major:

Minor:

Are you presently attending school or taking classes?:

Yes No

If "yes," where are you enrolled and what course of study are you pursuing?:

If your profession requires registration, licensure or certification, please provide the necessary information.

In your profession, are you currently:

Registered Licensed Certified

If not, are you eligible for:

Registration Licensure Certification

If registered, licensed or certified please indicate:

Type / Date

Issuing State

License Number

Expiration

Type / Date

Issuing State

License Number

Expiration

Type / Date

Issuing State

License Number

Expiration

List three business/work references' names, addresses, phone numbers, and number of years know (do not include relatives or previous supervisors). If not applicable, list three school or personal references who are not related to you.

Reference Name 1:

Daytime Phone Number:

- Area Code Phone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Years Known:

Reference Name 2:

Daytime Phone Number:

- Area Code Phone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Years Known:

Reference Name 3:

Daytime Phone Number:

- Area Code Phone Number

Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Years Known:

List professional, trade, business, or civic association memberships; accomplishments, awards, or publications. You may exclude information that reveals race, color, religion, national origin, marital status, age, gender, disability, or veteran status.

I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions. I certify that all statements made by me on this application are complete to the best of my knowledge and I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

Incomplete applications will not be considered .

By typing my name in the following box I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information:*

Date:*

- Month - Day Year

Click rounded arrow for encrypted message to appear. Then enter the message as it's shown*

Employment History

Educational History

Licensure/Certification

References

Additional Information