This is a lengthy application. Please read carefully and complete all possible information. Applications with incomplete necessary details will be discredited.

For those holding college degrees, please be sure to attach resume' at the bottom.

Give the following information about any license, certificate, or other authorization to practice a trade or profession.

Noting that we do not have “day” shifts (7a-3p, 8a-4p, etc.) what hours will you NOT be able to work?

Please note that pending charges or convictions will not be used or considered unless they are substantially related to circumstances of the particular job.

If charges have been removed from your record or dropped, you WILL be asked to bring the paperwork showing this.

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driving a vehicle for our company will be part of your job duties, has your license to operate a motor vehicle ever been revoked or suspended?

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.

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?

In case of emergency, notify:

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.

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.

I have no medical condition that would prevent me from performing the essential functions of the job for which I have applied.

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.

If submitting a resume', please include at least 3 other employers with the above information.