Job Application

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Important Information to Know Before Filling Out an Application for Employment with Mineral Community Hospital

1. All areas of the application must be filled out completely and accurately. Please fill in all the required information directly on the application and do not indicate “see resume”. Please also attach your resume if you have one towards the end of this form.

2. If you are offered a position with Mineral Community Hospital, be aware that we may verify all of the information that you have written on the application, as well as your resume. If there is a discrepancy in your information, the job offer may be withdrawn. It is important to be sure that what you have written is correct.

3. If you have any questions about completing the application, it is important to please ask the Human Resource Director.

Thank you for your cooperation.

Applicant Acknowledgement

My signature below indicates that I have read and understand the importance of supplying accurate information on the application. I am also aware of the possibility of an offer of employment being withdrawn if any of the information is not correct.

"*" indicates required fields

Signature*

Date*

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date You Can Begin

Position Applied For

Wage Desired

Level & Type of Education

High School (Name)

(City & State)

(Year Complete/Graduate? Y/N)

College/University (Name)

(City & State)

(Year Complete/Degree)

Other Schools (Name)

(City & State)

(Year Complete/Degree)

Special Skills

Software Applications:

Other Skills:

Employment Record

Please list your most recent jobs first. Include military service as part of your employment record. If you have a resume, please attach it to this form located just above form submission button.

Employer

Supervisor's Name

Telephone Number

Job Title

Dates of Employment (month & year)

From: To:

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Salary

Starting Salary Ending Salary

Essential Job Duties

Reason for Leaving

Employment Record Cont.

Employer

Supervisor's Name

Telephone Number

Job Title

Dates of Employment (month & year)

From: To:

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Salary

Starting Salary Ending Salary

Essential Job Duties

Reason for Leaving

Employment Record Cont.

Employer

Supervisor's Name

Telephone Number

Job Title

Dates of Employment (month & year)

From: To:

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Salary

Starting Salary Ending Salary

Essential Job Duties

Reason for Leaving

General Information

May we contact your present/past employers?*

Yes

Do you have the legal right to work in the United States? (if hired, you will be required to provide identification to prove eligibility for employment)*

Yes

Have you been employed or attended school using any other name? If yes, please indicate:*

Yes

Name

First Last

Have you ever been convicted, pled guilty or no contest, or forfeited bond or bail for any crime other than traffic violations?*

Yes

(Conviction of a crime is not an automatic bar to employment. Factors such as the nature and gravity of the crime, the length of time that has passed since the conviction and/or completion on any sentence, and the nature of the job for which you have applied will be considered)

Are you able to perform the primary duties of the job as outlined in the newspaper advertisement, announcement, posting, job line, job description, with or without reasonable accommodation?*

Yes

If no, please explain:

Additional Information:

Please use the space provided to list any additional employers, periods of time not worked, or any other information that you believe we should know in considering your application for employment.

Additional References:

Name Title

Agency/Company Phone Number

Name Title

Agency/Company Phone Number

Name Title

Agency/Company Phone Number

Please read carefully, initial each paragraph and sign below:

I certify that I have answered the above questions truthfully and have not withheld any information relative to my application. I understand that any falsification, misrepresentation, or omission, as well as any misleading statements or omissions of the application information, attachments, and supporting documents generally may result in denial of employment or immediate termination, if discovered after hire.*

I authorize Mineral Community Hospital to thoroughly investigate my references, work record, education and other matters related to my suitability for employment, and further authorize the references I have listed to disclose to the company any and all letter, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I release Mineral Community Hospital, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.*

I authorize Mineral Community Hospital to investigate whether I have a criminal record of convictions, and, if so, the nature of such convictions and all the surrounding circumstances of the conviction. Mineral Community Hospital has advised me that any criminal background check will focus on convictions, and that a criminal record will not necessarily disqualify me from employment.*

Signature

Date

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