Citizens Medical Center

List Professional, business or civic activities and offices held. (Exclude groups which indicate race, color, religion, sex, or national origin);
Give name, address and telephone number of three references not related to you:
Special Employment Notice To Disabled Veterans, Vietnam Era Veterans, And Individuals with Physical or Mental Handicaps:

Government contractors are subject to Sections 402 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affimative action to employ and advance in employment qualified handicapped individuals.

If you are a disabled veteran, or have a physical or mental handicap, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner. This information will be treated as confidential. Failure to provide this information will not jepordize or adversely affect any consideration you may receive for employment.
If you wish to be identified, please sign below.

Handicapped IndividualDisabled VeteranVietnam Era Veteran
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EMPLOYMENT HISTORY
List each job held. Start with your present or last job. Include military service assignments and volunteer activities. (Exclude groups which indicate race, color, religion, sex or national origin.)
Employer
Started Left No./Yr. Mo./Yr.
Complete Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone Number
Please enter a valid phone number.
Type of Work
Immediate Supervisor
Rate of pay - Start/Left
Reason for Leaving
May we contact your present employer?

YesNo

Employer
Started Left No./Yr. Mo./Yr.
Complete Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone No.
Please enter a valid phone number.
Type of Work
Immediate Supervisor
Rate of pay - Start/Left
Reason for Leaving
May we contact your present employer?

YesNo

Summarize special skills and qualifications acquired from employment or other experience:
List any Honors received from school, college, etc.:
State any additional information you may feel may be helpful to us in considering your application:
Remarks:
I understand and agree that Citizens Medical Center may make inquiries to verify information on this application, particularly relating to prior employment and education. In addition, an investigation into my character and general reputation may be conducted and persons, including references listed in the application, may be contacted for this purpose. My signature below authorizes Citizens Medical Center to do so. I understand that any false or misleading information or omissions in this application shall be sufficient cause for rejection or immediate dismissal. The use of this application does not indicate that there are positions open and does not in any way obligate the Hospital. If employed, I will conform to the rules and regulations of Citizens Medical Center and my employment and compensation may be terminated with or without cause and with or without notice, at any time, at the option of either the Hospital or myself. I hereby acknowlegde that I have read and fully understand the foregoing statement.

I understand that if employed, my employment is for no definite period and no manager or employee has the authority to enter into an employment contract with me in behalf of the hospital.

I also understand and agree, if employed, not to: engage in outside business ventures which would interfere with my duties as an employee; provide consulting or other services for firms in compeition with the hospital or engage in any activity in competition with Citizens Medical Center; have any substantial interest in a firm which supplies goods or services to the hospital; or accept from suppliers or competitors any gifts worth more than $25.00.
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Date
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Citizens Medical Center

Education

EMPLOYMENT HISTORY