Permian Regional Medical Center - Application for Employment

Permian Regional Medical Center - Application for Employment
It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

Human Resources Department
720 Hospital Drive
Andrews, Texas 79714
Name*

First NameLast Name
Other Last Names Used*
Please enter N/A if none.
Date*

MonthDayYear
Date
Are You At Least 18 Years Old?*

YesNo
Last 4-digits of SSN*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment History*

	Employer 1	Employer 2	Employer 3
Company Name
Company Phone
Supervisor's Name
Job Title
Employment Dates (Start-Stop)
Job Responsibilities (Brief Description)

Educational History*

	School Info. (Name of School, City, State)	Years Attended	Graduated? (Degree or Certificate?)
High School
College
College
Graduate School
Other

List any professional licenses, registration or certification you possess:*
(Include only the last 4 digits of your Driver's License, if applicable). Please include Type, State Issued, Expiration Date and Number. Indicate if any licenses have been revoked, suspended or placed on probation. Also indicate if you are ineligible to become licensed or certified in your field. Please explain.
Clerical or other skills applicable to the position for which you are applying? *
Please enter N/A if none.
Software Proficiency?*
Please enter N/A if none.
Business machines and/or equipment you can operate:*
Please enter N/A if none.
Anything Else?
Should be Empty: