Online Application Form War Memorial Hospital

Secure 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.

* First Name:

* Last Name:

* Middle Initial:

* Social Security #:

* Present Address:

* Present City:

* Present State:

* Present ZIP:

Previous Address:

Previous City:

Previous State:

Previous ZIP:

* Home And Cell Phone:

E-Mail Address:

* Date Available For Work

* Salary Requirements:

* Are you at least 18 year of age? Yes No

* Are You Legally Authorized to Work in the U.S.? Yes No

* Are you willing to travel? Yes No

* Are you willing to Relocate? Yes No

* Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? Yes No

* If overtime work is required periodically, does this pose a problem for you? Yes No

* Have you ever worked in this or any other facility? Yes No
If yes, what facility?

* Are you related to another facility employee? Yes No
If yes, who?

* Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations? Yes No
Describe any accommodations necessary:

* Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? Arrests or charges that have been expunged need not be disclosed. Yes No
If yes, give date, place and nature of each such conviction.

* Are you presently charged with any violation of the law? Yes No
If yes, give date, place and nature of each such event:

* Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program? Yes No

Education History

High School

* Name of School:

* City:

* State:

* Graduated/GED:

Degree:

College

Name of School:

City:

State:

# of Years Completed:

Graduated:

Degree:

College

Name of School:

City:

State:

# of Years Completed:

Graduated:

Degree:

Graduate School

Name of School:

City:

State:

Attended:

Graduated:

Degree:

Other

Name of School:

City:

State:

Attended:

Graduated:

Degree:

Additional

Name of School:

City:

State:

Attended:

Graduated:

Degree:

List any professional licenses, registration or certification you possess (Include Driver's License, if applicable) 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

Typing (WPM)

PBX

Proficient in Software:

Business machines and/or equipment you can operate:

Other