Employment Application

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.


Personal Information

Emergency Contact

Background Information

Military Service

High School


Graduate/Professional School

Other School

Professional Registration, Licensure, Accreditation or Certification
Certificate 1

Certificate 2

Certificate 3

Certificate 4


Specialized Skills - check skills/equipment operated

Reference Information
Reference 1

Reference 2


Give a complete record of all employment and reasons for periods of unemployment during past ten years. Start with most recent employment. Give U.S. experience only.

Employer 1

Employer 2

Employer 3

Employer 4

Employer 5



I understand that this is an application for employment and that no employment contract is being offered at this time. Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal or, or if employed, immediate termination of employment.

It is my understanding that the hospital will make a through investigation of my entire work and personal history and may verify all data given in my application for employment, related paper, or interviews. I authorize such investigation and the giving and receiving of any information requested by the hospital and I release from liability any person giving or receiving any such information. I understand that falsification of data so given or other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to disciplinary action or dismissal.

I understand that I must be able to perform the position tasks for which I’ve applied. I must complete a preplacement physical examination by a qualified medical physician and flexibility screening by the hospital Physical Therapist at no cost to me. Also, if employed, I must complete future physical examinations as required by the hospital at my own cost. I authorize any physician or hospital to release any information verbally or in writing, which may be necessary to determine my abilities to satisfactorily perform the job duties I am applying for are and are employed therein.

I further agree that if employed, I will serve the hospital to the best of my abilities and abide by the established policies. I understand that if I do not, I may be subject to disciplinary action and /or dismissal.