Mountain Lakes Medical Center

Employment Application Form:

(WE ARE AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER)
Your failure to fully and completely answer each inquiry on this application may disqualify you from consideration for employment
Personal Information:
Full Name *

First Name Middle Name Last Name
Are you 18 years of age or older? *

Yes No
Phone Number *

Area Code Phone Number
Cell Number *

Area Code Phone Number
E-mail *
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Employment Desired:
Position Desired:
Days available to work:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Shifts Available to work:

7am-7pm 7pm-7am Any
Placement Desired:

Full-Time Part-Time Temporary
Current Employment:
Current Employer
Name of Current Employer or NONE if not Employed
Start Date

Month Day Year
Salary
Job Title
Phone Number:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reason for Leaving?
Duties:
Reason for Leaving (provide detailed response)
May We Contact?

Yes No
Previous Employment:

Please list the names of your previous employers in chronological order with present or last employer listed first. Include part-time and seasonal employment. Be sure to account for all periods of time, including military service and any period of unemployment. If self-employed, give company name and supply business references. You may also attach a detailed resume at the end of this application.
Previous Employer
Name of Previous Employer
Start Date

Month Day Year
End Date

Month Day Year
Ending Salary
Job Title
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Last Supervisor's Name and Title
Duties
Reason for Leaving (provide detailed response)
Previous Employer
Name of Previous Employer
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Ending Salary
Job Title
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Last Supervisor's Name and Title
Duties
Reason for Leaving (provide detailed response)
Previous Employer
Name of Previous Employer
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Ending Salary
Job Title
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Last Supervisor's Name and Title
Duties
Reason for Leaving (provide detailed response)
Background Information
If hired, can you provide proof that you are legally entitled to work in the U.S.? *

Yes No
Have you ever worked for Mountain Lakes Medical Center? *

Yes No
If yes, please give dates and position:
Are you related to anyone currently employed by Mountain Lakes Medical Center? *

Yes No
If so, whom?
Have you ever been convicted of a criminal offense (felony or misdemeaner)? *

Yes No
Are any charges currently pending against you? *

Yes No
(NOTE: Answering “yes” to these questions does not constitute an automatic bar to employment). If you answered yes to any of the preceding questions, please give dates and details:
Education
High School
Years Completed

9 10 11 12
Diploma/Degree
Describe Course of Study or Magor
Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities
College/University
Years Completed

1 2 3 4
Diploma/Degree
Describe Course of Study or Major
Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities
Graduate/Professional
Years Completed

1 2 3 4
Diploma/Degree
Describe Course of Study or Major
Describe Specialized Experience, Training, Skills, and Extra-Curricular Activities
Personal References:
Reference 1
Name of Reference
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Years Acquainted
Phone
Email
Reference 1
Name of Reference
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Years Acquainted
Phone
Email
Reference 1
Name of Reference
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Years Acquainted
Phone
Email
Applicant's Statement
I understand that Mountain Lakes Medical Center (the “Company”) is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer, and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, religion, handicap or disability, or any other category protected by federal, state, or local law.

By my signature below I attest that the information given by me on this application is true and complete in all respects, and I agree that if the information is found to be false, misleading, incomplete, or unsatisfactory in any respect (as determined by Mountain Lakes Medical Center in its sole judgment) I will be disqualified from consideration for employment or subject to immediate dismissal if discovered after I am hired.

Thank you for submitting

Human Resource Department
Date *

Month Day Year
Date
Signature *

Clear
Please verify that you are human *
THIS APPLICATION WILL BE CONSIDERED “ACTIVE” FOR A MAXIMUM OF THIRTY (30) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.
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Employment Application Form:

Personal Information:

Employment Desired:

Current Employment:

Previous Employment:

Background Information

Education

Personal References:

Applicant's Statement