Personal Information

Full Name:

Social Security Number:

Present Address:
Street:
City:
State:
Zip:

Home Phone Number:
Business Phone Number:

In case of emergency, notify...
Name:
Address:
Phone Number:

Employment Desired

Position:

Date you can start:

*Are you employed now? YesNo
*If so, may we contact your employer? YesNo

*I can work...
Days
Evenings
Nights
Rotating

*I want to work...
Full Time
Part Time
Either

How many days per week can you work?

*Will you work on call, if necessary? YesNo
*Will you work other shifts in emergencies? YesNo

*Note: Double-check the *'d fields before submitting, especially if you got an error.

Who referred you to Vernon Memorial Healthcare?
Have you been employed here before?
Do you have relatives in our employ? If so, please list them.

Education

(only job related education is considered prior to hiring)

High School:
Name:
Location:
Number of years attended:
Date of graduation:
Diploma, degree, or certificate recieved:

College:
Name:
Location:
Number of years attended:
Date of graduation:
Diploma, degree, or certificate recieved:

Other:
Name:
Location:
Number of years attended:
Date of graduation:
Diploma, degree, or certificate recieved:

Other professional training, certificates, or skills which you feel would relate to the position for which you are applying:

Former Employers

Most recent employer:

Name of employer:
Starting date: (month/year):
Leaving date: (month/year):
Final salary:
Title and primary duties:
Name and title of supervisor:
Phone number of supervisor:
Reason for leaving:

Second most recent:

Name of employer:
Starting date: (month/year):
Leaving date: (month/year):
Final salary:
Title and primary duties:
Name and title of supervisor:
Phone number of supervisor:
Reason for leaving:

Third most recent:

Name of employer:
Starting date: (month/year):
Leaving date: (month/year):
Final salary:
Title and primary duties:
Name and title of supervisor:
Phone number of supervisor:
Reason for leaving:

References

Reference 1:

Name:
Address:
Phone Number:
Occupation:
Years Known:

Reference 2:

Name:
Address:
Phone Number:
Occupation:
Years Known:

Reference 3:

Name:
Address:
Phone Number:
Occupation:
Years Known:

Service Record

U.S. Military or Naval Service:
Rank:

Present Membership in National Guard or Reserves:
Date:
Obligation Ends:

Discharge Date:
Type of Discharge:

By submitting this form, I voluntarily give this institution the right to make a through 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 consent to take the post-offer physical examination, and I agree to complete any other Employee Health requirements as deemed necessary by this institution.

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

I further understand that Vernon Memorial Healthcare is an equal opportunity employer and does not discriminate in hiring or other employment practices on the basis of race, color, religion, creed, national origin, sex or sexual orientation, age, handicap, marital status, arrest record, conviction record, or membership in the national guard, state defence force or any reserve component of the military forces of the United States or this state.

I understand that if employed I will be placed on a training period for 90 days. An associate may resign or be dismissed without prior notice during the training period.

Upon my termination I authorize the release of reference information regarding my employment.

[Signature is implied by clicking "Submit"]

As a condition of employment, you will be required to produce original documents establishing your identity and authorization to work and to complete the U.S. Immigration and Naturalization Services Form 1-9.

Applicant Release

I hereby request and authorize any and all of my former employers and any other persons indicated as a reference to furnish to the hospital, any information regarding my previous employment, the dates thereof, position held, job performance, dependability and personal characteristics, except where my written statement upon this form specifically requests no investigation be made. Moreover, I hereby release each employer and/or reference from any and all liability for furnishing such information to the hospital. A copy of this release used by Vernon Memorial Healthcare is the same as the original.

[Signature is implied by clicking "Submit"]