Otto Kaiser - Application for Employment

Application for Employment

Otto Kaiser Memorial Hospital
This organization complies with all federal, state, and local equal opportunity laws and guidelines.

PLEASE COMPLETE ALL ITEMS. ENTER N/A IF ITEM DOES NOT APPLY TO YOU
What position are you applying for?*
Today's Date*

MonthDayYear
Date
Date Available*

MonthDayYear
Date
Please attach your resume*

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PERSONAL INFORMATION
Name*

First NameLast Name
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Home Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Why do you choose hospital work?*
What prompted you to apply here for employment?*
Type a question*
Do you have any hobbies?*
IN CASE OF EMERGENCY PLEASE NOTIFY
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*
Phone Number*
Please enter a valid phone number.
EDUCATION, LICENSES & CERTIFICATES

Please fill out the table below*

	Name of School	Diploma or Degree Received	Major Field of Studies	Month/Year
High School
Vocational
College
Graduate
Training

EMPLOYMENT RECORD

List all employment, starting with most recent position and working back.
Employment Record One
(1) Name of Company*
(1) Salary*
(1) Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Position Held*
(1) Start & Finish Date*
(1) Duties & Responsibilities*
(1) Supervisor*
(1) Salary*
Employment Record Two
(2) Name of Company*
(2) Phone Number*
Please enter a valid phone number.
(2) Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Position Held*
(2) Start & Finish Date*
(2) Duties & Responsibilities*
(2) Supervisor*
(2) Phone Number*
Please enter a valid phone number.
Employment Record Three
(3) Name of Company*
(3) Phone Number*
Please enter a valid phone number.
(3) Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(3) Position Held*
(3) Start & Finish Date*
(3) Duties & Responsibilities*
(3) Supervisor*
(3) Phone Number*
Please enter a valid phone number.
REFERENCES

Please provide three references familiar with your work experience.*

	Name of Reference	Address	Phone Number
One
Two

CRIMINAL HISTORY & TRAFFIC VIOLATIONS
Have you been convicted of a felony within the last 10 years?*
If so, what was the conviction?*
Where was the conviction?*
Provide county & state
Do you have any moving violations or accidents on your driving record?*
NOTICE OF PHYSICAL TESTING
This organization is committed to maintaining a drug free workplace. All candidates for employment are required to complete a physical examination and drug test.
APPLICATION ACKNOWLEDGEMENT
I agree to undergo pre-employment drug testing. I understand that the results of the testing will be disclosed only to the human resources department and relevant management employees. I understand that if I refuse to complete this testing I will not be considered for employment.

I grant this organization permission to conduct an investigation and solicit information related to my educational and employment history. I release this organization and any of its employees or agents from any liabilities arising from such investigation.

I understand this is an Application for Employment and does not grant me any right to employment with this organization.

If employment is offered as a result of this Application for Employment, I understand, if I have knowingly and willfully concealed information requested by this application or made any false representations concerning my medical condition I will not be entitled to any workers' compenstation benefits if I am injured while working for this organization.

ALL STATEMENTS MADE AND INFORMATION PROVIDED BY ME ON THIS APPLICATION FOR EMPLOYMENT ARE TRUE AND CORRECT.

I UNDERSTAND ANY FALSE, INACCURATE, OMITTED OR MISLEADING STATEMENTS CAN BE GROUNDS FOR REJECTION OF MY APPLICATION OR TERMINATION FROM EMPLOYMENT IF I AM HIRED BY THIS COMPANY.

I HAVE READ, UNDERSTAND AND BY SIGNATURE VERIFY THE STATEMENTS AND INFORMATION I HAVE PROVIDED ON THIS APPLICATION FOR EMPLOYMENT.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Application for Employment

PERSONAL INFORMATION

IN CASE OF EMERGENCY PLEASE NOTIFY

EDUCATION, LICENSES & CERTIFICATES

EMPLOYMENT RECORD

REFERENCES

CRIMINAL HISTORY & TRAFFIC VIOLATIONS

NOTICE OF PHYSICAL TESTING

APPLICATION ACKNOWLEDGEMENT