Hammond-Henry Hospital

Employment Application

In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include but is not limited to a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends.

PERSONAL INFORMATION

Last Name *   First Name *   Middle Name  
 
Permanent Address * City * State * Zip Code *
Present Address (if different) City State Zip Code
Best Time To Contact You Email Address Contact Phone * Home Phone
Any Previous Name(s)? If Yes, identify all other names including maiden name
 
Position Applied For Interested In: Would You Consider Working: Shift Availability:



Weekends/Holidays
Rotating Shifts
On Call
Any Shift



 
 
Date Available For Work *   How Did You Learn About This Position? (Newspaper, Internet, Friend, if other - please list)

 
Salary Desired

Relative or Friends Employed at HHH? If Yes, Name(s) Department(s) Relationship
 
Have You Ever Been Employed At Hammond-Henry Hospital?         When? 
Are You 18 Years Of Age Or Older?   
Are You A U.S. Citizen Or An Alien Legally Authorized To Work In The United States?   
Long Range Occupational Goals

EDUCATION / SKILLS

School Name and
Address of School
Course of Study Year
Completed
Did You
Graduate?
List Diploma or
Degree
High

College


College

OTHER Business College or Special Courses(Include Special Military Training, Post Graduate and Nursing)
Area(s) of Specialization or Major Interest List Office Skills (Include Computer/Software Exp.)
List Health Care, Business, or Industrial Equipment Operated Word Processing (Approx. WPM)

PROFESSIONAL LICENSES AND CERTIFICATIONS

Professional Licenses   Professional Certifications


License or Registration ever Suspended,
Revoked or On Probation?
(If Yes, Explain)

Type     State   Type
Number Date    State  Date
 


License or Registration ever Suspended,
Revoked or On Probation?
(If Yes, Explain)

Type     State   Type
Number Date    State  Date

PREVIOUS EXPERIENCE

Briefly describe duties and skills acquired through military or volunteer service (include dates)
 
Provide information regarding Previous Employment beginning with the most recent Employer.
  From (mm/yy)  To (mm/yy) Supervisor's Name Salary (Hr/Mo/Yr)
Job Title 1 (most recent)       
Employer Name    Phone
Address      
Duties
Reason for Leaving
May we contact your Current Employer?
 
  From (mm/yy)  To (mm/yy) Supervisor's Name Salary (Hr/Mo/Yr)
Job Title 2       
Employer Name    Phone
Address      
Duties
Reason for Leaving
 
  From (mm/yy)  To (mm/yy) Supervisor's Name Salary (Hr/Mo/Yr)
Job Title 3       
Employer Name    Phone
Address      
Duties
Reason for Leaving
 
  From (mm/yy)  To (mm/yy) Supervisor's Name Salary (Hr/Mo/Yr)
Job Title 4       
Employer Name    Phone
Address      
Duties
Reason for Leaving
 
Please identify and explain any gaps in employment longer than three (3) months
Cover Letter (optional, plain text format)
Resume / CV (optional, plaint text format)

REFERENCES

Name and Relationship Title Company Name and Address Telephone

Signature - Please read carefully before checking the 'Agree' box

I hereby affirm that the information provided on the application (and cover letter and/or resume, if any) is true and complete. I understand that any false or misleading representation or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment.

I understand that if the job for which I am hired requires licensing and/or certifications, keeping such documents current and unencumbered is a continuing requirement as long as I hold the position.

I hereby authorized persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

By checking the box below, I agree to the above and my application will be submitted to Human Resources. By not checking, I will not be allowed to submit my application.

      Signature *            Date *  

(* Denotes required fields)