This is a lengthy application. Please read carefully and complete all possible information. Applications with incomplete necessary details will be discredited.
PERSONAL
First name:
*
Last name:
*
E-mail:
*
Telephone Number:
Address:
Applying for Position:
When can you start?
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Month
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Day
Year
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Minutes
AM
PM
AM/PM Option
Work Status
Full-time
Part-time
Either
EDUCATION
High School Name & Location
Last great attended
Please Select
9
10
11
12
Achieved
HS Diploma
G.E.D.
None
Last year attended
For those holding college degrees, please be sure to attach resume' at the bottom.
PROFESSIONAL LICENSE
Give the following information about any license, certificate, or other authorization to practice a trade or profession.
Name of trade/profession
License # (not driver's license)
Granted by (licensing agency)
City or State of
Speciality
Date 1st license issued
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Month
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Day
Year
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Minutes
AM
PM
AM/PM Option
CURRENT OR MOST RECENT EMPLOYMENT
Can we contact your current employer?
Yes
No
Contact me before you do
Dates of hire
Employer
Title or Position
Duties performed
Starting Salary
Reason for wanting to leave.
Supervisor
Employer contact #
Additional Information
Have you ever worked for G.B. Cooley before?
Yes
No
If so, when?
Position Held
Who was your Supervisor?
Reason for leaving?
Noting that we do not have “day” shifts (7a-3p, 8a-4p, etc.) what hours will you NOT be able to work?
Hours
7:00am – 3:00pm
8:00am – 4:00pm
3:00pm – 11:00pm
4:00pm – 12:00am
11:00pm – 7:00am
12:00am – 8:00am
Can you work weekends?
Yes
No
Criminal & Driving Record
Please note that pending charges or convictions will not be used or considered unless they are substantially related to circumstances of the particular job.
Have you ever been convicted of an violations other than minor traffic violations?
Yes
No
If yes, give violation convicted of.
Date of conviction
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Month
-
Day
Year
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10
20
30
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Minutes
AM
PM
AM/PM Option
State of conviction
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
If charges have been removed from your record or dropped, you WILL be asked to bring the paperwork showing this.
Have the charges been removed or dropped?
Yes
No
Do you possess a valid driver’s license?
Yes
No
What state issued the license?
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
License Number
Valid until
Have you had a license in another state within the past 3 years?
Yes
No
Since driving a vehicle for our company will be part of your job duties, has your license to operate a motor vehicle ever been revoked or suspended?
License issues?
Yes
No
Have you had any traffic accidents in the past 3 years?
Yes
No
Have you received any traffic tickets in the past 3 years?
Yes
No
References
List 4 people who are NOT related to you and who have a definite knowledge of your qualifications and fitness for the position for which you are applying. DO NOT LIST FORMER SUPERVISORS OR RELATIVES.
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
Name
Address
Phone
Do you have any relatives living, working or on the board of G.B. Cooley? If yes, please list who and your relationship.
PRE-EMPLOYMENT AUTHORIZATION and CERTIFICATIONS
Do you agree that if you are employed by G.B.Cooley Hospital Service District, employer shall thereafter at any time and from time to time have the right to require a medical examination by a licensed physician of your physical or mental condition, to include (but be limited to) X-ray examination and laboratory tests, and that it shall further be a condition of your employment that you be mentally and physically qualified (as determined by medical examination) to perform the assigned duties of your position?
Agree?
Yes
No
In case of emergency, notify:
Emergency Contact
Phone
In an attempt to judge the effectiveness of our recruitment efforts, we request that you provide the following optional information. This information will, in no way be used in the decision to hire or promote.
Sex
Male
Female
Race
White
Black
Orientala
Spanish-American
Other
Veteran Status
Non-Veteran
Viet Nam Era
Disabled
Other Veteran
Date of Birth
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Month
-
Day
Year
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50
Minutes
AM
PM
AM/PM Option
IN ACCORDANCE WITH Section 504 of the Rehabilitation Act of 1973, a “Handicapped Person” means any person: (1.) With a physical or mental impairment which substantially limits one or more major life activities; (2.) With a record of such an impairment; or (3.) Who is regarded as having such impairment.
Do you feel you qualify?
Yes
No
Please state nature of handicap or disability.
I have no medical condition that would prevent me from performing the essential functions of the job for which I have applied.
Agree?
Yes
No
How did you learn of this vacancy? (If employee, please give name)
It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.
By selecting agree below, I give G.B.Cooley Hospital Service District the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its’ representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.
AGREE?
*
Yes
No
If submitting a resume', please include at least 3 other employers with the above information.
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