Decatur Health Employment Application

EDUCATION (1)
Type of School

High SchoolCollege or UniversityTrade or Correspondence SchoolOther
Years Attended
Name of School
Location of School
City, State
Degree Received
Subjects Studied / Major

EDUCATION (2)
Type of School

High SchoolCollege or UniversityTrade or Correspondence SchoolOther
Years Attended
Name of School
Location of School
City, State
Degree Received
Subjects Studied / Major

EDUCATION (3)
Type of School

High SchoolCollege or UniversityTrade or Correspondence SchoolOther
Years Attended
Name of School
Location of School
City, State
Degree Received
Subjects Studied / Major

EDUCATION (4)
Type of School

High SchoolCollege or UniversityTrade or Correspondence SchoolOther
Years Attended
Name of School
Location of School
City, State
Degree Received
Subjects Studied / Major

EMPLOYMENT HISTORY (1)

Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backwards in time. Incomplete information could disqualify you from further consideration.
Employer Name
Employer Phone
e.g. 555-555-5555
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Wage
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving

EMPLOYMENT HISTORY (2)
Employer Name
Employer Phone
e.g. 555-555-5555
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Wage
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving

EMPLOYMENT HISTORY (3)
Employer Name
Employer Phone
e.g. 555-555-5555
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Wage
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving

EMPLOYMENT HISTORY (4)
Employer Name
Employer Phone
e.g. 555-555-5555
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Wage
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving

EMPLOYMENT HISTORY (5)
Employer Name
Employer Phone
e.g. 555-555-5555
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Start Date

MonthDayYear
End Date

MonthDayYear
Job Title
Wage
Immediate Supervisor and Title
Summarize the nature of work performed and job responsibilities
Reason for leaving

SKILLS
Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, explain.
Computer Skills (please describe):
PROFESSIONAL REFERENCES
Name

First NameLast Name
Company
Phone Number
e.g. 555-555-5555
Name

First NameLast Name
Company
Phone Number
e.g. 555-555-5555
Name

First NameLast Name
Company
Phone Number
e.g. 555-555-5555

Please read carefully before submitting your application.

Decatur Health is an equal opportunity employer. Decatur Health does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Decatur Health to hire me. If I am hired, I understand that either Decatur Health or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Decatur Health has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to Decatur Health true and complete information on this application. No requested information has been concealed.

I authorize Decatur Health to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal. I understand that if I am offered a job, I consent to undergo a physical examination which related to the essential duties I would be required to perform, drug screen, and criminal record check.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.
I have read the information in this agreement.
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THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM DATE SUBMITTED.
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