Cimarron Memorial Job Application Form

Job Application

Cimarron Memorial Hospital
Personal Information
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Social Security Number
Date of Birth

MonthDayYear
Date
Phone Number
Email
example@example.com
Position Applying For
Department
Hours Available to Work
Days Available to Work

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Have you ever worked for Cimarron Memorial Hospital?
If so, who was your supervisor?
Have you ever been discharged or asked to resign from a job?
If yes, please explain:
Record of Education
High School
Name
City
State
Years completed
College
Name
City
State
Degree Earned
Other
Name
City
State
Degree Earned
Skills & Qualifications
Licenses, skills, trainings, awards
Personal References
Name
Mailing Address
City, State, ZIP
Phone Number
Please enter a valid phone number.
Name
Mailing Address
City, State, ZIP
Phone Number
Please enter a valid phone number.
Name
Mailing Address
City, State, ZIP
Phone Number
Please enter a valid phone number.
Are there any circumstances that might limit your ability to perform the job you are applying for?
Please explain
Present or last place of employment
Employer
Address
Street or PO box, city, state, ZIP code
State/City/Zip
Street or PO box, city, state, ZIP code
Supervisor
Supervisor's email
PH #
Your Position
From date

MonthDayYear
Date
To date

MonthDayYear
Date
Reasons for leaving
Your responsibilities
May we contact this employer?
Previous employment
Employer
Address
Street or PO box, city, state, ZIP code
City/State/Zip Code
Street or PO box, city, state, ZIP code
Supervisor
Supervisor's Email
PH #
Your Position
From date

MonthDayYear
Date
To date

MonthDayYear
Date
Reasons for leaving
Your responsibilities
May we contact this employer?
Employment Verification Authorization
I, First Name Last Name authorize my previous employer(s) to release information pertaining to me while employed by them. I am aware that an employment reference check will be conducted by Cimarron Memorial and I grant my permission for previous employers to release information to Cimarron Memorial.
Employee's Signature

Clear
Date

MonthDayYear
Date
Social Security Number
Date

MonthDayYear
Date
Cimarron Memorial does not discriminate in hiring or in any other decision on the basis of Race, Religion, Sex, Citizenship, National Origin, Ancestry, or on the basis of Age or Physical or Mental Disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give Cimarron Memorial the right to make a thorough investigation of my Past Employment & 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 Physical Examination and / or Screenings and future physical exams as may be required by Cimarron Memorial at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical exam which relates to the essential duties I would be required to perform. I understand that my employment is all at-will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an employment verification FORM I-9 and show satisfactory evidence of identity and eligibility for employment. I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future, if I am hire. I authorize the verification of any or all information listed above.
Signature

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Job Application

Personal Information

Record of Education

High School

College

Other

Personal References

Present or last place of employment

Previous employment

Employment Verification Authorization